Provider Demographics
NPI:1750542221
Name:ROSE DRUG OF DANVILLE INC
Entity type:Organization
Organization Name:ROSE DRUG OF DANVILLE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA
Authorized Official - Phone:479-495-7673
Mailing Address - Street 1:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-0471
Mailing Address - Country:US
Mailing Address - Phone:870-246-5553
Mailing Address - Fax:870-246-6616
Practice Address - Street 1:708 E 8TH STREET
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833
Practice Address - Country:US
Practice Address - Phone:479-495-7673
Practice Address - Fax:479-495-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
ARAR205833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0422890OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AR168234407Medicaid