Provider Demographics
NPI:1699789545
Name:D.L. BAKER DRUG CO., INC.
Entity type:Organization
Organization Name:D.L. BAKER DRUG CO., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ISSA
Authorized Official - Last Name:KASSISSIEH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:501-945-3264
Mailing Address - Street 1:4307 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-4124
Mailing Address - Country:US
Mailing Address - Phone:501-945-3264
Mailing Address - Fax:501-945-6976
Practice Address - Street 1:4307 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-4124
Practice Address - Country:US
Practice Address - Phone:501-945-3264
Practice Address - Fax:501-945-6976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06101183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100180407Medicaid