Healthcare Provider Details

I. General information

NPI: 1083027148
Provider Name (Legal Business Name): FORREST ETHRIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 E HIGHLAND DR STE A
JONESBORO AR
72401-6376
US

IV. Provider business mailing address

3000 E HIGHLAND DR STE A
JONESBORO AR
72401-6376
US

V. Phone/Fax

Practice location:
  • Phone: 870-934-9668
  • Fax:
Mailing address:
  • Phone: 870-934-9668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number07033
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: