Healthcare Provider Details

I. General information

NPI: 1225516701
Provider Name (Legal Business Name): MALORIE MORELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 W WALNUT ST
ROGERS AR
72756-3246
US

IV. Provider business mailing address

39 ALTON CIR
ROGERS AR
72756-9252
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-8238
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPD14596
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: