Provider Demographics
NPI:1912537713
Name:MEDIC PHARMACY INC OF EL DORADO
Entity Type:Organization
Organization Name:MEDIC PHARMACY INC OF EL DORADO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECH
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:TECH
Authorized Official - Phone:870-862-4931
Mailing Address - Street 1:347 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4564
Mailing Address - Country:US
Mailing Address - Phone:870-862-4931
Mailing Address - Fax:870-862-6659
Practice Address - Street 1:347 W OAK ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4564
Practice Address - Country:US
Practice Address - Phone:870-862-4931
Practice Address - Fax:870-862-6659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDIC PHARMACY INC OF EL DORADO ARKANSAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100136407Medicaid