Provider Demographics
NPI:1760629984
Name:STAGECOACH PHARMACY LLC
Entity Type:Organization
Organization Name:STAGECOACH PHARMACY LLC
Other - Org Name:STAGECOACH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKSDALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-455-6295
Mailing Address - Street 1:1 STAGECOACH VLG
Mailing Address - Street 2:STE 2
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-4750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 STAGECOACH VLG
Practice Address - Street 2:STE 2
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-4750
Practice Address - Country:US
Practice Address - Phone:501-455-6295
Practice Address - Fax:501-455-1917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR205983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0423068OtherNCPDP PROVIDER IDENTIFICATION NUMBER