Provider Demographics
NPI:1659064236
Name:COLLIER DRUG STORES INC
Entity Type:Organization
Organization Name:COLLIER DRUG STORES INC
Other - Org Name:COLLIER DRUG - WILLOW CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:479-442-6262
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1085
Mailing Address - Country:US
Mailing Address - Phone:479-442-6262
Mailing Address - Fax:479-521-9111
Practice Address - Street 1:5201 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0876
Practice Address - Country:US
Practice Address - Phone:479-521-7876
Practice Address - Fax:479-521-7889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-31
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127467407Medicaid