Healthcare Provider Details

I. General information

NPI: 1346528056
Provider Name (Legal Business Name): GORDON RAY MUTTERS P.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 06/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 MARKET TRCE
FORT SMITH AR
72908-8677
US

IV. Provider business mailing address

7700 HIGHWAY 271 S
FORT SMITH AR
72908-8028
US

V. Phone/Fax

Practice location:
  • Phone: 479-646-5505
  • Fax: 479-646-3090
Mailing address:
  • Phone: 479-646-7875
  • Fax: 479-646-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberAR07041
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: