Provider Demographics
NPI:1619246493
Name:AMERICAN HOME PHARMACY LLC
Entity Type:Organization
Organization Name:AMERICAN HOME PHARMACY LLC
Other - Org Name:AMERICAN HOME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-745-4266
Mailing Address - Street 1:PO BOX 1060
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-1060
Mailing Address - Country:US
Mailing Address - Phone:501-745-4266
Mailing Address - Fax:501-745-5707
Practice Address - Street 1:454 INGRAM ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-7078
Practice Address - Country:US
Practice Address - Phone:501-745-4266
Practice Address - Fax:501-745-5707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
ARAR206393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190897407Medicaid
2133298OtherPK