Healthcare Provider Details

I. General information

NPI: 1417549528
Provider Name (Legal Business Name): JOHN DAVID HUMPHRIES PD PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E VAN BUREN
EUREKA SPRINGS AR
72632-3653
US

IV. Provider business mailing address

133 E VAN BUREN
EUREKA SPRINGS AR
72632-3653
US

V. Phone/Fax

Practice location:
  • Phone: 479-253-9175
  • Fax: 479-253-8460
Mailing address:
  • Phone: 479-253-9175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD07251
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: