Basic Information
| Provider Information | |||||||||
| NPI: | 1306449913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | DIEDRA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1172 HWY 7 NORTH | ||||||||
| Address2: | |||||||||
| City: | DARDANELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792292157 | ||||||||
| FaxNumber: | 4792291648 | ||||||||
| Practice Location | |||||||||
| Address1: | 1172 HIGHWAY 7 NORTH | ||||||||
| Address2: | |||||||||
| City: | DARDANELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792292157 | ||||||||
| FaxNumber: | 4792291648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2020 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD07614 | AR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.