Healthcare Provider Details

I. General information

NPI: 1669727939
Provider Name (Legal Business Name): ATHENA L LEWALLEN PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 SALEM RD
CONWAY AR
72034-4815
US

IV. Provider business mailing address

601 N SAINT JOSEPH ST
MORRILTON AR
72110-2104
US

V. Phone/Fax

Practice location:
  • Phone: 501-328-3117
  • Fax:
Mailing address:
  • Phone: 501-354-4669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD11975
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: