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General NPI Number Information
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NPI Number | 1164081071
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Entity Type | Organization
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Legal Business Name | FOUNTAIN LAKE FAMILY PHARMACY LLC
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Dates
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Enumeration Date | 06/13/2019
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Last Update Date | 07/21/2020
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Provider Practice Location Address
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Address Line | 4517 PARK AVE SUITE B
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City | HOT SPRINGS
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State | AR
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Zip | 71901
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Country | US
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Telephone | 501-547-3400
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Fax | 844-805-7790
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Provider Business Mailing Address
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Address Line | 4517 PARK AVE SUITE B
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City | HOT SPRINGS
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State | AR
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Zip | 71901
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Country | US
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Telephone | 501-547-3400
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Fax | 844-805-7790
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL DAVID BUTLER
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Credential | PHARMD
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Telephone | 501-547-3400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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