Provider Demographics
NPI:1841336765
Name:BELLA VISTA PHARMACY, INC
Entity type:Organization
Organization Name:BELLA VISTA PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER, PHARMTECH
Authorized Official - Prefix:MR
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:B
Authorized Official - Last Name:BEDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-855-3791
Mailing Address - Street 1:408 TOWN CTR NE
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-1817
Mailing Address - Country:US
Mailing Address - Phone:479-855-3791
Mailing Address - Fax:479-876-5881
Practice Address - Street 1:408 TOWN CTR NE
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-1817
Practice Address - Country:US
Practice Address - Phone:479-855-3791
Practice Address - Fax:479-876-5881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR119503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR10641OtherPTAN
AR10641OtherPTAN