Provider Demographics
NPI:1609323922
Name:RED RIVER PHARMACY OF JONESBORO LLC
Entity Type:Organization
Organization Name:RED RIVER PHARMACY OF JONESBORO LLC
Other - Org Name:RED RIVER INFUSION PHARMACY OF JONESBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-792-7435
Mailing Address - Street 1:1550 MOORES LN
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4657
Mailing Address - Country:US
Mailing Address - Phone:903-792-7435
Mailing Address - Fax:903-793-0485
Practice Address - Street 1:2908 S CARAWAY RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7346
Practice Address - Country:US
Practice Address - Phone:870-336-2195
Practice Address - Fax:870-336-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-02
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251F00000X, 332B00000X, 332BP3500X, 3336H0001X, 3336N0007X
ARAR20653333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336N0007XSuppliersPharmacyNuclear Pharmacy
No251F00000XAgenciesHome Infusion
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164238OtherPK
7627810001OtherPTAN