Provider Demographics
NPI:1285167502
Name:NW OTTER CREEK LLC
Entity type:Organization
Organization Name:NW OTTER CREEK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAINOR NAMIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-773-0359
Mailing Address - Street 1:PO BOX 7791
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72217-7791
Mailing Address - Country:US
Mailing Address - Phone:855-553-9777
Mailing Address - Fax:501-246-3842
Practice Address - Street 1:10100 STAGECOACH RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-5742
Practice Address - Country:US
Practice Address - Phone:501-455-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221379407Medicaid