=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871194068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNA CASSAT PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2020
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 BRYANT AVE
-----------------------------------------------------
City | BRYANT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72022-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-847-4615
-----------------------------------------------------
Fax | 501-847-7693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7710 S SHORELINE BLVD
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72019-8472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-690-4704
-----------------------------------------------------
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 | PD11316
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------