Provider Demographics
NPI:1609879808
Name:HEALTH DEPOT PHARMACIES, LLC
Entity Type:Organization
Organization Name:HEALTH DEPOT PHARMACIES, LLC
Other - Org Name:HEALTH DEPOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BREANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-646-7875
Mailing Address - Street 1:7700 HWY 271 S.
Mailing Address - Street 2:
Mailing Address - City:FT. SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908
Mailing Address - Country:US
Mailing Address - Phone:479-649-9500
Mailing Address - Fax:479-649-9504
Practice Address - Street 1:7700 HWY 271 S
Practice Address - Street 2:
Practice Address - City:FT. SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908
Practice Address - Country:US
Practice Address - Phone:479-649-9500
Practice Address - Fax:479-649-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110632716Medicaid
OK100245080AMedicaid
AR221611716Medicaid
OK100245080AMedicaid