Provider Demographics
NPI:1780665034
Name:MITCHELLS PARK STREET PHARMACY INC
Entity type:Organization
Organization Name:MITCHELLS PARK STREET PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-297-8107
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0569
Mailing Address - Country:US
Mailing Address - Phone:870-297-8107
Mailing Address - Fax:870-297-8799
Practice Address - Street 1:526 PARK ST
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519-9070
Practice Address - Country:US
Practice Address - Phone:870-297-8107
Practice Address - Fax:870-297-8799
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AM DIAMONDS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-11
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117614716Medicaid
AR117614716Medicaid