Healthcare Provider Details

I. General information

NPI: 1760824445
Provider Name (Legal Business Name): MALLORY MICHELLE TYLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY MICHELLE WATTS PHARMD

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W BROADWAY ST
WEST MEMPHIS AR
72301-2904
US

IV. Provider business mailing address

430 W BROADWAY ST
WEST MEMPHIS AR
72301-2904
US

V. Phone/Fax

Practice location:
  • Phone: 870-394-3060
  • Fax: 888-804-2856
Mailing address:
  • Phone: 870-394-3060
  • Fax: 888-804-2856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD12399
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: