Healthcare Provider Details

I. General information

NPI: 1649781436
Provider Name (Legal Business Name): MALCOLM J STUBBS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 KALISTE SALOOM RD STE 102
LAFAYETTE LA
70508-5784
US

IV. Provider business mailing address

PO BOX 3328
BENTONVILLE AR
72712
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-9702
  • Fax: 877-427-2307
Mailing address:
  • Phone: 479-636-9702
  • Fax: 877-427-2307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number10732R
License Number StateLA

VIII. Authorized Official

Name: MACKENZIE HAHN
Title or Position: NCPDP COORDINATOR
Credential:
Phone: 479-636-9702