Healthcare Provider Details

I. General information

NPI: 1609480185
Provider Name (Legal Business Name): HUMPHREY TAYONG TEKUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/02/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 W 28TH AVE
PINE BLUFF AR
71603-5053
US

IV. Provider business mailing address

119 LAMARCHE PLACE
LITTLE ROCK AR
72223
US

V. Phone/Fax

Practice location:
  • Phone: 879-870-6084
  • Fax:
Mailing address:
  • Phone: 612-598-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD13863
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: