Provider Demographics
NPI:1285656363
Name:CHAMBLESS, ALTON
Entity Type:Individual
Prefix:
First Name:ALTON
Middle Name:
Last Name:CHAMBLESS
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 1:1109 LEE ST.
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042
Mailing Address - Country:US
Mailing Address - Phone:870-946-1048
Mailing Address - Fax:
Practice Address - Street 1:1626 S MADISON ST
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:AR
Practice Address - Zip Code:72042-3003
Practice Address - Country:US
Practice Address - Phone:870-946-1706
Practice Address - Fax:870-946-3024
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist