Provider Demographics
NPI:1285221267
Name:LOVELY, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:LOVELY
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 1:1800 N MISSOURI ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-1750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 N MISSOURI ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-1750
Practice Address - Country:US
Practice Address - Phone:870-735-8987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist