Provider Demographics
NPI:1295752376
Name:MARVELL CLINIC PHARMACY, INC.
Entity type:Organization
Organization Name:MARVELL CLINIC PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARM
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:870-829-1044
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:406 S. MILL ST
Mailing Address - City:MARVELL
Mailing Address - State:AR
Mailing Address - Zip Code:72366-0217
Mailing Address - Country:US
Mailing Address - Phone:870-829-1044
Mailing Address - Fax:870-829-1067
Practice Address - Street 1:406 S MILL ST
Practice Address - Street 2:
Practice Address - City:MARVEL
Practice Address - State:AR
Practice Address - Zip Code:72366-0217
Practice Address - Country:US
Practice Address - Phone:870-829-1044
Practice Address - Fax:870-829-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR20373332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5743090001Medicare NSC