=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467129825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALVERN FAMILY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2021
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72104-2217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-732-7950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 902 MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72104-2217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-732-7950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY OPERATIONS MANAGER
-----------------------------------------------------
Name | TODD BEAGLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-642-2620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------