Healthcare Provider Details

I. General information

NPI: 1013912765
Provider Name (Legal Business Name): DOUGLAS A BALTZ PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 W STRAWN AVE
JONESBORO AR
72401-3982
US

IV. Provider business mailing address

642 W STRAWN AVE
JONESBORO AR
72401-3982
US

V. Phone/Fax

Practice location:
  • Phone: 870-935-0294
  • Fax:
Mailing address:
  • Phone: 870-935-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6612
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2000165328
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number6612
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number2000165328
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number6612
License Number StateAR
# 6
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number2000165328
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: