MEDICARE: DR. DUSTIN EZELL PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PD12618	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PD12618	OTHER	AR	ARKANSAS PHARMACISTS LICENSE

General Provider Information

NPI Number	:	1144633132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DUSTIN EZELL PHARMD

Provider Business Mailing Address
First Line	:	6044 ALLWOOD DR
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72116-3706
Country	:	US
Telephone Number	:	501-765-1776
Fax Number	:	501-945-6976

Provider Business Practice Location Address
First Line	:	2609 MCCAIN BLVD
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72116-8013
Country	:	US
Telephone Number	:	501-353-1984
Fax Number	:	501-353-2698

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2014
Last Update Date	:	06/06/2014

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