Healthcare Provider Details

I. General information

NPI: 1114670189
Provider Name (Legal Business Name): AUSTIN SEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 N STATE LINE AVE
TEXARKANA AR
71854-1934
US

IV. Provider business mailing address

3 LAMBETH CIR
TEXARKANA TX
75503-2556
US

V. Phone/Fax

Practice location:
  • Phone: 870-773-5521
  • Fax:
Mailing address:
  • Phone: 903-556-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPD15889
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: