Basic Information
Provider Information | |||||||||
NPI: | 1639779291 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCKINTON | ||||||||
FirstName: | KELLEY | ||||||||
MiddleName: | BROOK | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8174 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 720788174 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016501343 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8801 HIGHWAY 107 | ||||||||
Address2: |   | ||||||||
City: | SHERWOOD | ||||||||
State: | AR | ||||||||
PostalCode: | 721202929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5018333116 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2020 | ||||||||
LastUpdateDate: | 10/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835C0205X | PD09208 | AR | Y |   |   |   |   |
No ID Information.