=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922697291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK VO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 834 E HENRI DE TONTI BLVD
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-4124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-927-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5704 CHAPEN DR
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72916-8962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-648-0007
-----------------------------------------------------
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 | R-18888
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PD14162
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------