Provider Demographics
NPI:1740420157
Name:DE QUEEN HEALTH AND WELLNESS PHARMACY LLC
Entity Type:Organization
Organization Name:DE QUEEN HEALTH AND WELLNESS PHARMACY LLC
Other - Org Name:DE QUEEN HEALTH AND WELLNESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-642-2400
Mailing Address - Street 1:1357 W COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2946
Mailing Address - Country:US
Mailing Address - Phone:870-642-4458
Mailing Address - Fax:870-642-5526
Practice Address - Street 1:1357 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2946
Practice Address - Country:US
Practice Address - Phone:870-642-4458
Practice Address - Fax:870-642-5526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
ARAR202213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200018110AMedicaid
AR155535407Medicaid
AR164404716Medicaid
0421026OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AR155535407Medicaid