Provider Demographics
NPI:1063286607
Name:MONTICELLO DRUG COMPANY LLC
Entity type:Organization
Organization Name:MONTICELLO DRUG COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-2220
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-0552
Mailing Address - Country:US
Mailing Address - Phone:870-265-2220
Mailing Address - Fax:870-265-2226
Practice Address - Street 1:201 E GAINES ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4903
Practice Address - Country:US
Practice Address - Phone:870-367-5301
Practice Address - Fax:870-460-0257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy