Provider Demographics
NPI:1790479087
Name:STATE LINE PHARMACY, PLLC
Entity Type:Organization
Organization Name:STATE LINE PHARMACY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:870-843-6028
Mailing Address - Street 1:PO BOX 720
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:AR
Mailing Address - Zip Code:71749-0720
Mailing Address - Country:US
Mailing Address - Phone:870-843-6028
Mailing Address - Fax:
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:AR
Practice Address - Zip Code:71749-9501
Practice Address - Country:US
Practice Address - Phone:870-843-6028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy