Provider Demographics
NPI:1144363219
Name:CITY DRUG OF MONTICELLO INC
Entity type:Organization
Organization Name:CITY DRUG OF MONTICELLO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:870-265-2220
Mailing Address - Street 1:201 E GAINES ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-4903
Mailing Address - Country:US
Mailing Address - Phone:870-367-5301
Mailing Address - Fax:870-460-0257
Practice Address - Street 1:201 E GAINES ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4903
Practice Address - Country:US
Practice Address - Phone:870-367-5301
Practice Address - Fax:870-460-0257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111058416Medicaid
0417350001Medicare ID - Type Unspecified