Provider Demographics
NPI:1932271590
Name:ROACH ENTERPRISES INC
Entity Type:Organization
Organization Name:ROACH ENTERPRISES INC
Other - Org Name:FAMILY CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONNI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:870-358-2484
Mailing Address - Street 1:98 HIGHWAY 63B STE A
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARKED TREE
Mailing Address - State:AR
Mailing Address - Zip Code:72365-1614
Mailing Address - Country:US
Mailing Address - Phone:870-358-2484
Mailing Address - Fax:
Practice Address - Street 1:98 HIGHWAY 63B STE A
Practice Address - Street 2:SUITE A
Practice Address - City:MARKED TREE
Practice Address - State:AR
Practice Address - Zip Code:72365-1614
Practice Address - Country:US
Practice Address - Phone:870-358-2484
Practice Address - Fax:870-358-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
ARAR203143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145129407Medicaid
AR146998716Medicaid
1995153OtherPK
AR146998716Medicaid