Provider Demographics
NPI:1508847179
Name:SMITHS COUNTRY CLUB DRUG STORE INC
Entity Type:Organization
Organization Name:SMITHS COUNTRY CLUB DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:INGELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-663-4118
Mailing Address - Street 1:5114 KAVANAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4607
Mailing Address - Country:US
Mailing Address - Phone:501-663-4118
Mailing Address - Fax:501-663-4110
Practice Address - Street 1:5114 KAVANAUGH BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-4607
Practice Address - Country:US
Practice Address - Phone:501-663-4118
Practice Address - Fax:501-663-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0419211Medicaid
1217280001Medicare NSC