Provider Demographics
NPI:1174624829
Name:CARL STANLEY DUCKWORTH P A
Entity type:Organization
Organization Name:CARL STANLEY DUCKWORTH P A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:870-886-3461
Mailing Address - Street 1:218 W MAIN ST
Mailing Address - Street 2:PO BOX 469
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-1933
Mailing Address - Country:US
Mailing Address - Phone:870-886-3461
Mailing Address - Fax:870-886-3503
Practice Address - Street 1:218 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1933
Practice Address - Country:US
Practice Address - Phone:870-886-3461
Practice Address - Fax:870-886-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
ARAR159963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115144407Medicaid
1994900OtherPK