NPIMap

Organization Active NPI

Smiths Country Club Drug Store Inc

  • Community/Retail Pharmacy
  • Little Rock, AR
National Provider Identifier
1841339645
Registry record updated Jun 13, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
AR19211 Issued in AR
Legal business name
SMITHS COUNTRY CLUB DRUG STORE INC
Doing business as
SMITHS COUNTRY CLUB DRUG STORE INC
Practice address
5114 Kavanaugh Blvd
Little Rock, AR 72207-4607
Phone
(501) 663-4118
Fax
(501) 663-4110
NPI assigned
Feb 6, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 13, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Patricia IngelsNPI 1063182558
Title
President
Phone
(501) 663-4118

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X AR19211 AR Primary
Long Term Care Pharmacy 3336L0003X

Addresses

Primary practice location

5114 Kavanaugh Blvd
Little Rock, AR 72207-4607

Mailing address

5114 Kavanaugh Blvd
Little Rock, AR 72207-4607
Phone (501) 663-4118

Other identifiers 2

IdentifierTypeStateIssuer
160237407MedicaidAR
1988096OtherPK

Other names 1

  • SMITHS COUNTRY CLUB DRUG STORE INC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040109001020 AR Part B Supplier - Mass Immunization (Roster Biller Only) 1951201607 Practice locations: Little Rock, AR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Smiths Country Club Drug Store Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

5114 Kavanaugh Blvd
Little Rock, AR 72207
Phone (501) 663-4118

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1465776000000",
    "number": "1841339645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5114 KAVANAUGH BLVD",
            "city": "LITTLE ROCK",
            "state": "AR",
            "postal_code": "722074607",
            "telephone_number": "501-663-4118",
            "fax_number": "501-663-4110"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5114 KAVANAUGH BLVD",
            "city": "LITTLE ROCK",
            "state": "AR",
            "postal_code": "722074607",
            "telephone_number": "501-663-4118",
            "fax_number": "501-663-4110"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SMITHS COUNTRY CLUB DRUG STORE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-06",
        "last_updated": "2016-06-13",
        "status": "A",
        "authorized_official_last_name": "INGELS",
        "authorized_official_first_name": "PATRICIA",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "501-663-4118"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "AR",
            "license": "AR19211",
            "primary": true
        },
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "160237407",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "1988096",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SMITHS COUNTRY CLUB DRUG STORE INC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Little Rock, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.