Provider Demographics
NPI:1093353922
Name:FAGALA, PHIL
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:FAGALA
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 1:614 NORTH BEECHWOOD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-666-7997
Mailing Address - Fax:
Practice Address - Street 1:614 NORTH BEECHWOOD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-666-7997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD10040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist