Basic Information
| Provider Information | |||||||||
| NPI: | 1427659606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | QINMI | ||||||||
| MiddleName: | AMY | ||||||||
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| Credential: | PHARMACIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 S SEATTLE AVE | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728015604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794989540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2109 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794989540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD12835 | AR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.