Healthcare Provider Details

I. General information

NPI: 1770685083
Provider Name (Legal Business Name): MARY CAROLE M POLK RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON STREET
CLARENDON AR
72029
US

IV. Provider business mailing address

55 NORMANDY LN
LITTLE ROCK AR
72207-4201
US

V. Phone/Fax

Practice location:
  • Phone: 870-747-3304
  • Fax:
Mailing address:
  • Phone: 501-690-7519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7925
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: