Provider Demographics
NPI:1427058593
Name:COLLIER DRUG STORES INC
Entity type:Organization
Organization Name:COLLIER DRUG STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-442-6262
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1085
Mailing Address - Country:US
Mailing Address - Phone:479-442-6262
Mailing Address - Fax:479-521-9111
Practice Address - Street 1:197 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-3077
Practice Address - Country:US
Practice Address - Phone:479-267-4303
Practice Address - Fax:479-267-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR146773336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112025407Medicaid
1994731OtherPK