Provider Demographics
NPI:1891786885
Name:MINERAL SPRINGS DRUG STORE, INC.
Entity Type:Organization
Organization Name:MINERAL SPRINGS DRUG STORE, INC.
Other - Org Name:MINERAL SPRINGS PHARMACY AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-PRES-PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:KARON
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:BAXLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-287-4455
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:MINERAL SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71851-0249
Mailing Address - Country:US
Mailing Address - Phone:870-287-4455
Mailing Address - Fax:870-287-4721
Practice Address - Street 1:400 RUNNELS STREET
Practice Address - Street 2:
Practice Address - City:MINERAL SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71851-0249
Practice Address - Country:US
Practice Address - Phone:870-287-4455
Practice Address - Fax:870-287-4721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR-14413333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy