Provider Demographics
NPI:1922418615
Name:PALACE DRUG OF SALEM LLC
Entity Type:Organization
Organization Name:PALACE DRUG OF SALEM LLC
Other - Org Name:PALACE DRUG OF SALEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-625-3222
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-0247
Mailing Address - Country:US
Mailing Address - Phone:870-895-3811
Mailing Address - Fax:870-895-3836
Practice Address - Street 1:106 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-8059
Practice Address - Country:US
Practice Address - Phone:870-895-3811
Practice Address - Fax:870-895-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR05957333600000X
3336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146649OtherPK
AR7173550001Medicare NSC