Provider Demographics
NPI:1366554354
Name:MCKINNEY DRUG STORES INC
Entity type:Organization
Organization Name:MCKINNEY DRUG STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:479-751-4536
Mailing Address - Street 1:601 W MAPLE AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5335
Mailing Address - Country:US
Mailing Address - Phone:479-751-4536
Mailing Address - Fax:479-751-2031
Practice Address - Street 1:601 W MAPLE AVE
Practice Address - Street 2:STE 201
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-751-4536
Practice Address - Fax:479-751-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR005893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100391407Medicaid
1992745OtherPK
AR100391407Medicaid