Healthcare Provider Details

I. General information

NPI: 1558098210
Provider Name (Legal Business Name): VAN ALLEN CLAYTON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 W MAIN ST
WALNUT RIDGE AR
72476-1005
US

IV. Provider business mailing address

124 CHARLESTON DR
WALNUT RIDGE AR
72476-8552
US

V. Phone/Fax

Practice location:
  • Phone: 870-886-8100
  • Fax: 870-886-9200
Mailing address:
  • Phone: 870-637-2162
  • Fax: 870-886-9200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD08346
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: