Provider Demographics
NPI:1962553404
Name:TOMMYS REXALL DRUG COMPANY INC.
Entity type:Organization
Organization Name:TOMMYS REXALL DRUG COMPANY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-946-4221
Mailing Address - Street 1:220 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-2057
Mailing Address - Country:US
Mailing Address - Phone:870-946-4221
Mailing Address - Fax:870-946-1181
Practice Address - Street 1:220 COURT SQ
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:AR
Practice Address - Zip Code:72042-2057
Practice Address - Country:US
Practice Address - Phone:870-946-4221
Practice Address - Fax:870-946-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR14071183500000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100643407Medicaid
AR120942716Medicaid
AR120942716Medicaid