Provider Demographics
NPI:1235727892
Name:PETTY, COLBY
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:
Last Name:PETTY
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 1:400 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4218
Mailing Address - Country:US
Mailing Address - Phone:501-516-5984
Mailing Address - Fax:
Practice Address - Street 1:615 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021-2507
Practice Address - Country:US
Practice Address - Phone:501-516-5984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist