Healthcare Provider Details

I. General information

NPI: 1841286572
Provider Name (Legal Business Name): MAYBRANCH PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 OLD GREENWOOD RD STE. 11
FORT SMITH AR
72903-4560
US

IV. Provider business mailing address

2801 OLD GREENWOOD RD STE. 11
FORT SMITH AR
72903-4560
US

V. Phone/Fax

Practice location:
  • Phone: 479-646-3434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberAR20274
License Number StateAR

VIII. Authorized Official

Name: GORDON RAY MUTTERS
Title or Position: PHARMACIST
Credential:
Phone: 479-646-3434