Provider Demographics
NPI:1053047290
Name:POWELL, BRENT ALLEN
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALLEN
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 HEMINGWAY CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-5572
Mailing Address - Country:US
Mailing Address - Phone:601-248-6588
Mailing Address - Fax:
Practice Address - Street 1:1815 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6118
Practice Address - Country:US
Practice Address - Phone:870-972-1838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist