Provider Demographics
NPI:1922192327
Name:BOBBY TEETERS DRUG STORE INC
Entity Type:Organization
Organization Name:BOBBY TEETERS DRUG STORE INC
Other - Org Name:BOBBY TEETERS DRUG STORE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PIC
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TEETER
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:479-754-2196
Mailing Address - Street 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3010
Mailing Address - Country:US
Mailing Address - Phone:479-754-2196
Mailing Address - Fax:479-754-8885
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3010
Practice Address - Country:US
Practice Address - Phone:479-754-2196
Practice Address - Fax:479-754-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR118473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0411847OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AR100098407Medicaid