Provider Demographics
NPI:1013220730
Name:KOSTELNIK, MARK ANDREW (PHARMD, BCPS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:KOSTELNIK
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 E MILLSAP RD STE 3
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6289
Mailing Address - Country:US
Mailing Address - Phone:918-809-7822
Mailing Address - Fax:479-445-6032
Practice Address - Street 1:375 E MILLSAP RD STE 3
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6289
Practice Address - Country:US
Practice Address - Phone:918-809-7822
Practice Address - Fax:479-445-6032
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14707183500000X
ARPD144101835C0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0207XPharmacy Service ProvidersPharmacistCompounded Sterile Preparations
No183500000XPharmacy Service ProvidersPharmacist