Provider Demographics
NPI:1093858698
Name:KAVANAUGH PHARMACY
Entity type:Organization
Organization Name:KAVANAUGH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:501-664-3844
Mailing Address - Street 1:5008 KAVANAUGH BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4747
Mailing Address - Country:US
Mailing Address - Phone:501-664-3844
Mailing Address - Fax:
Practice Address - Street 1:5008 KAVANAUGH BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-4747
Practice Address - Country:US
Practice Address - Phone:501-664-3844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR041833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0404183OtherNCPDP NUMBER
AK3211202OtherDEA NUMBER