=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255438917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE STROUD EWALD RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5001 N STATE LINE AVE STE C
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-2962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-785-4197
-----------------------------------------------------
Fax | 877-737-9135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 STONERIDGE CIR
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-838-9647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 27433
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9347
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 11840
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 12236
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 033937
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 17557
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------