=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831791730
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLTON MOORMAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2020
-----------------------------------------------------
Last Update Date | 11/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 ATLANTA ST SE
-----------------------------------------------------
City | GRAVETTE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72736-9364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-787-5966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15603 BIRD MOUNTAIN RD
-----------------------------------------------------
City | SULPHUR SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72768-9091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | PD13952
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------