Healthcare Provider Details

I. General information

NPI: 1235213539
Provider Name (Legal Business Name): BRANDY LEANN GAINES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MAIN ST
BRINKLEY AR
72021-2507
US

IV. Provider business mailing address

117 S 2ND ST PO BOX 497
AUGUSTA AR
72006-2309
US

V. Phone/Fax

Practice location:
  • Phone: 870-734-1153
  • Fax: 870-734-1179
Mailing address:
  • Phone: 870-347-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT89535
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD11925
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: