Provider Demographics
NPI:1023099660
Name:COLLEGE PHARMACY INC
Entity type:Organization
Organization Name:COLLEGE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-234-7292
Mailing Address - Street 1:211 E STADIUM
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2032
Mailing Address - Country:US
Mailing Address - Phone:870-234-7292
Mailing Address - Fax:870-234-4443
Practice Address - Street 1:211 E STADIUM
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2032
Practice Address - Country:US
Practice Address - Phone:870-234-7292
Practice Address - Fax:870-234-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 333600000X
ARAR200423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112438407Medicaid
LA1275361Medicaid
1994732OtherPK
0264140001Medicare NSC