Provider Demographics
NPI:1942399043
Name:DAVIS DRUG STORE INC
Entity Type:Organization
Organization Name:DAVIS DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-856-3080
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-0428
Mailing Address - Country:US
Mailing Address - Phone:870-856-3080
Mailing Address - Fax:870-856-4165
Practice Address - Street 1:1645 HWY 62 167
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:AR
Practice Address - Zip Code:72542
Practice Address - Country:US
Practice Address - Phone:870-856-3080
Practice Address - Fax:870-856-4165
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVIS DRUG STORE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149049716Medicaid
4643100001Medicare NSC