Provider Demographics
NPI:1528058112
Name:IMBODEN MEDICAL PHARMACY INC
Entity type:Organization
Organization Name:IMBODEN MEDICAL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEVAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:PP
Authorized Official - Phone:870-869-2046
Mailing Address - Street 1:203 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:IMBODEN
Mailing Address - State:AR
Mailing Address - Zip Code:72434
Mailing Address - Country:US
Mailing Address - Phone:870-869-2046
Mailing Address - Fax:870-869-3302
Practice Address - Street 1:203 WALNUT ST
Practice Address - Street 2:
Practice Address - City:IMBODEN
Practice Address - State:AR
Practice Address - Zip Code:72434
Practice Address - Country:US
Practice Address - Phone:870-869-2046
Practice Address - Fax:870-869-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0410047OtherNABPH
0712200001Medicare ID - Type Unspecified