Healthcare Provider Details

I. General information

NPI: 1639509839
Provider Name (Legal Business Name): CHAD CORBIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 W BUCHANAN ST
PRAIRIE GROVE AR
72753-2880
US

IV. Provider business mailing address

881 W BUCHANAN ST
PRAIRIE GROVE AR
72753-2880
US

V. Phone/Fax

Practice location:
  • Phone: 479-846-6901
  • Fax: 479-846-6903
Mailing address:
  • Phone: 479-846-6901
  • Fax: 479-846-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD08924
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: