Provider Demographics
NPI:1275139016
Name:CODY, CANYON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CANYON
Middle Name:
Last Name:CODY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 BROOKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-9547
Mailing Address - Country:US
Mailing Address - Phone:501-303-8405
Mailing Address - Fax:
Practice Address - Street 1:146 THORNTON FERRY RD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-2544
Practice Address - Country:US
Practice Address - Phone:501-760-1283
Practice Address - Fax:501-760-1397
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020035183183500000X
ARPD12294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist