Provider Demographics
NPI:1942611504
Name:PORTLAND DRUG LLC
Entity Type:Organization
Organization Name:PORTLAND DRUG LLC
Other - Org Name:PORTLAND DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-2220
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-0552
Mailing Address - Country:US
Mailing Address - Phone:870-265-2220
Mailing Address - Fax:870-265-3538
Practice Address - Street 1:105 HIGHWAY 165 S
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:AR
Practice Address - Zip Code:71663-9251
Practice Address - Country:US
Practice Address - Phone:870-737-2813
Practice Address - Fax:870-737-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR114293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy