Healthcare Provider Details

I. General information

NPI: 1174940894
Provider Name (Legal Business Name): JACK DOWELL PITTMAN JR. DPH. GCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 HIGHWAY 336 W
CLINTON AR
72031-8311
US

IV. Provider business mailing address

3 SERGIO LN
HOT SPRINGS VILLAGE AR
71909-7929
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-8784
  • Fax:
Mailing address:
  • Phone: 501-472-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number9700
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: