Basic Information
Provider Information
NPI: 1518553726
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: SHAUN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PHARM D
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4420 JENNI LN
Address2:  
City: JONESBORO
State: AR
PostalCode: 724049045
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3319 HARRISBURG RD
Address2:  
City: JONESBORO
State: AR
PostalCode: 724048782
CountryCode: US
TelephoneNumber: 8702037087
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/12/2020
LastUpdateDate: 12/12/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/12/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XPD11927ARY Pharmacy Service ProvidersPharmacist 

No ID Information.


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