Provider Demographics
NPI:1689670457
Name:AMYCO INC
Entity Type:Organization
Organization Name:AMYCO INC
Other - Org Name:ANDERSON'S DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KANDICE
Authorized Official - Middle Name:AMY
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:479-782-2881
Mailing Address - Street 1:700 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4738
Mailing Address - Country:US
Mailing Address - Phone:479-782-2881
Mailing Address - Fax:479-782-3974
Practice Address - Street 1:700 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4738
Practice Address - Country:US
Practice Address - Phone:479-782-2881
Practice Address - Fax:479-782-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR72669333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK90003922622Medicaid
AR4504080001Medicare NSC