Healthcare Provider Details

I. General information

NPI: 1104484971
Provider Name (Legal Business Name): AUSTIN GILBREATH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970D ASH FLAT DR
ASH FLAT AR
72513-9533
US

IV. Provider business mailing address

PO BOX 278
ASH FLAT AR
72513-0278
US

V. Phone/Fax

Practice location:
  • Phone: 870-994-7377
  • Fax: 870-994-7399
Mailing address:
  • Phone: 870-994-7377
  • Fax: 870-994-7399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberAR01531
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: