=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538764097
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLYN J DILLARD PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2020
-----------------------------------------------------
Last Update Date | 12/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1007 HIGHWAY 65 S
-----------------------------------------------------
City | MC GEHEE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71654-9417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-222-6676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1007 HIGHWAY 65 S
-----------------------------------------------------
City | MC GEHEE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71654-9417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-222-6676
-----------------------------------------------------
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 | E-15069
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD14197
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------