Provider Demographics
NPI:1922375559
Name:MEDI SHOP PHARMACY
Entity Type:Organization
Organization Name:MEDI SHOP PHARMACY
Other - Org Name:MEDI SHOP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GEYER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:479-394-7476
Mailing Address - Street 1:204 HIGHWAY 71 S
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4638
Mailing Address - Country:US
Mailing Address - Phone:479-394-3254
Mailing Address - Fax:479-394-0235
Practice Address - Street 1:204 HIGHWAY 71 S
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4638
Practice Address - Country:US
Practice Address - Phone:479-394-3254
Practice Address - Fax:479-394-0235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
ARAR203833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190453407Medicaid
2133056OtherPK
2133056OtherPK