Healthcare Provider Details

I. General information

NPI: 1689749426
Provider Name (Legal Business Name): RONALD MYERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 MAIN
MAMMOTH SPRING AR
72554
US

IV. Provider business mailing address

P O BOX 69 226 MAIN ST
MAMMOTH SPRING AR
72554-0069
US

V. Phone/Fax

Practice location:
  • Phone: 870-625-3214
  • Fax: 870-625-3215
Mailing address:
  • Phone: 870-625-3214
  • Fax: 870-625-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberAM1358298
License Number StateAR

VIII. Authorized Official

Name: RONALD HAROLD MYERS
Title or Position: OWNER PHARMACIST
Credential: PD
Phone: 870-625-3214