Healthcare Provider Details

I. General information

NPI: 1811584956
Provider Name (Legal Business Name): BRETT RANDALL WALTERS PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 UNION ST
DARDANELLE AR
72834-3429
US

IV. Provider business mailing address

417 UNION ST
DARDANELLE AR
72834-3429
US

V. Phone/Fax

Practice location:
  • Phone: 479-229-4811
  • Fax: 479-229-5871
Mailing address:
  • Phone: 479-229-4811
  • Fax: 479-229-5871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD11665
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: