Provider Demographics
NPI:1811031065
Name:BUICE DRUG STORE
Entity type:Organization
Organization Name:BUICE DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIMBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-663-4133
Mailing Address - Street 1:3013 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5853
Mailing Address - Country:US
Mailing Address - Phone:501-663-4133
Mailing Address - Fax:501-663-0270
Practice Address - Street 1:3013 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5853
Practice Address - Country:US
Practice Address - Phone:501-663-4133
Practice Address - Fax:501-663-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD00083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100022704Medicaid