Provider Demographics
NPI:1396882122
Name:TOMMYS REXALL DRUG COMPANY INC
Entity type:Organization
Organization Name:TOMMYS REXALL DRUG COMPANY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-946-4221
Mailing Address - Street 1:220 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-2057
Mailing Address - Country:US
Mailing Address - Phone:870-946-4221
Mailing Address - Fax:870-946-1181
Practice Address - Street 1:220 COURT SQ
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:AR
Practice Address - Zip Code:72042-2057
Practice Address - Country:US
Practice Address - Phone:870-946-4221
Practice Address - Fax:870-946-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120942716Medicaid
0793550001Medicare NSC