=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992284939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY RISSINGER PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2018
-----------------------------------------------------
Last Update Date | 08/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2127 N CENTER ST STE 1
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-9449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-296-6041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2127 N CENTER ST STE 1
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-9449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-296-6041
-----------------------------------------------------
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 | PD08487
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------