=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386293041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRINKLEY FAMILY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2019
-----------------------------------------------------
Last Update Date | 11/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 PINECREST SUITE 8
-----------------------------------------------------
City | BRINKLEY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-830-7768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 249 CARLA DR
-----------------------------------------------------
City | CLARENDON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72029-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-319-1001
-----------------------------------------------------
Fax | 870-319-1002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/PIC
-----------------------------------------------------
Name | MARCO RENELL MIDDLETON SR.
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 870-830-7768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------