Provider Demographics
NPI:1760533509
Name:MONETTE DISCOUNT DRUG INC
Entity Type:Organization
Organization Name:MONETTE DISCOUNT DRUG INC
Other - Org Name:LEACHVILLE DISCOUNT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:LOMAX
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-275-9496
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:109 SOUTH MAIN
Mailing Address - City:LEACHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72438-0082
Mailing Address - Country:US
Mailing Address - Phone:870-539-6831
Mailing Address - Fax:870-539-6681
Practice Address - Street 1:109 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEACHVILLE
Practice Address - State:AR
Practice Address - Zip Code:72438-9097
Practice Address - Country:US
Practice Address - Phone:870-539-6831
Practice Address - Fax:870-539-6681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
ARAR157443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602470908Medicaid
0415744OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AR178642407Medicaid
FL0245161OtherDEA