Provider Demographics
NPI:1093439739
Name:PRINCE, JEFFREY DALE (PD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DALE
Last Name:PRINCE
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 EAST STADIUM DRIVE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2032
Mailing Address - Country:US
Mailing Address - Phone:870-234-7292
Mailing Address - Fax:870-234-4443
Practice Address - Street 1:211 EAST STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2032
Practice Address - Country:US
Practice Address - Phone:870-234-7292
Practice Address - Fax:870-234-4443
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR07513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist