Healthcare Provider Details

I. General information

NPI: 1750561734
Provider Name (Legal Business Name): MARCUS GENE COSTNER PHARMD, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

IV. Provider business mailing address

4300 W 7TH ST
LITTLE ROCK AR
72205-5446
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-4301
  • Fax:
Mailing address:
  • Phone: 501-257-1000
  • Fax: 501-257-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPD10479
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: