Healthcare Provider Details

I. General information

NPI: 1033483896
Provider Name (Legal Business Name): JASON PATRICK GILLAM PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2012
Last Update Date: 02/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 N RODNEY PARHAM RD
LITTLE ROCK AR
72227-4845
US

IV. Provider business mailing address

10300 N RODNEY PARHAM RD
LITTLE ROCK AR
72227-4845
US

V. Phone/Fax

Practice location:
  • Phone: 501-221-8304
  • Fax: 501-221-8303
Mailing address:
  • Phone: 501-221-8304
  • Fax: 501-221-8303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPD11058
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: