# ELLISVILLE DRUG ACQUISITION CO.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Ellisville Drug
- **Organization subpart:** No

## Provider details

- **NPI number:** 1396829438
- **Authorized official:** MR. DEBORAH R KEAVENY (CONTRACTING MANAGER)
- **Authorized official phone:** (612) 227-7811

## Contact information

- **Practice address:** 915 HILL ST, ELLISVILLE, MS 39437-2419
- **Practice address phone:** (601) 477-3573
- **Practice address fax:** (601) 477-3572
- **Mailing address:** 803 HIGHWAY 71 N, MENA, AR 71953-4367
- **Mailing address phone:** (479) 394-6363
- **Mailing address fax:** (479) 394-1046

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | 00140011 | MS | — |
| 3336C0003X | Community/Retail Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 10/25/2006
- **Last updated:** 04/27/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0330711 | — | MS |
| 01 | — | 2501218 | OTHER ID NUMBER-COMMERCIAL NUMBER | — |