Provider Demographics
NPI:1861585002
Name:CITY DRUG AND SODA FOUNTAIN
Entity type:Organization
Organization Name:CITY DRUG AND SODA FOUNTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-867-3310
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-0865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 W S WEST STREET
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957
Practice Address - Country:US
Practice Address - Phone:870-867-3310
Practice Address - Fax:870-867-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
ARAR18598333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0418598OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5591960001Medicare ID - Type Unspecified