Basic Information
Provider Information | |||||||||
NPI: | 1235213539 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAINES | ||||||||
FirstName: | BRANDY | ||||||||
MiddleName: | LEANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 117 S 2ND ST | ||||||||
Address2: | PO BOX 497 | ||||||||
City: | AUGUSTA | ||||||||
State: | AR | ||||||||
PostalCode: | 720062309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703472534 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 615 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BRINKLEY | ||||||||
State: | AR | ||||||||
PostalCode: | 720212507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707341153 | ||||||||
FaxNumber: | 8707341179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 04/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | PT89535 | AR | N |   | Pharmacy Service Providers | Pharmacy Technician |   | 183500000X | PD11925 | AR | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.