Provider Demographics
NPI:1952317422
Name:ROSE DRUG OF RUSSELLVILLE, INC
Entity Type:Organization
Organization Name:ROSE DRUG OF RUSSELLVILLE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ISSA
Authorized Official - Last Name:KASSISSIEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-945-3264
Mailing Address - Street 1:3103 W MAIN PL
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3360
Mailing Address - Country:US
Mailing Address - Phone:479-968-1050
Mailing Address - Fax:479-968-1557
Practice Address - Street 1:3103 W MAIN PL
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3360
Practice Address - Country:US
Practice Address - Phone:479-968-1050
Practice Address - Fax:479-968-1557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0413916332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110621716Medicaid