Organization
ELLISVILLE DRUG ACQUISITION CO.
Active
Other names
Ellisville Drug
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DEBORAH R KEAVENY (CONTRACTING MANAGER)
(612) 227-7811
Entity
Organization
Contact information
Practice address
915 HILL ST, ELLISVILLE, MS 39437-2419
(601) 477-3573
(601) 477-3572
Mailing address
803 HIGHWAY 71 N, MENA, AR 71953-4367
(479) 394-6363
(479) 394-1046
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
00140011
MS
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0330711
—
MS
01
—
2501218
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
10/25/2006
Last updated
04/27/2010
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