Provider Demographics
NPI:1750450607
Name:BLANDFORD PHARMACY
Entity Type:Organization
Organization Name:BLANDFORD PHARMACY
Other - Org Name:BLANFORD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-664-4466
Mailing Address - Street 1:5 SAINT VINCENT CIR
Mailing Address - Street 2:STE 110
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5412
Mailing Address - Country:US
Mailing Address - Phone:501-664-4466
Mailing Address - Fax:501-664-2360
Practice Address - Street 1:5 SAINT VINCENT CIR
Practice Address - Street 2:STE 110
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5412
Practice Address - Country:US
Practice Address - Phone:501-664-4466
Practice Address - Fax:501-664-2360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR132833336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110965407Medicaid
1994349OtherPK