Provider Demographics
NPI:1982997524
Name:WYNNE MEDICAL PHARMACY OF CROSS COUNTY INC
Entity Type:Organization
Organization Name:WYNNE MEDICAL PHARMACY OF CROSS COUNTY INC
Other - Org Name:WYNNE MEDICAL PHARMACY OF CROSS COUNTY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-793-3999
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0757
Mailing Address - Country:US
Mailing Address - Phone:870-238-8531
Mailing Address - Fax:870-238-5982
Practice Address - Street 1:718 FALLS BLVD S
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3514
Practice Address - Country:US
Practice Address - Phone:870-238-8531
Practice Address - Fax:870-238-5982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR065813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0423652OtherNCPDP PROVIDER IDENTIFICATION NUMBER