Provider Demographics
NPI:1336701721
Name:DUCKWORTH, MISTY RONETTE
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:RONETTE
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 COUNTY ROAD 7940
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-7266
Mailing Address - Country:US
Mailing Address - Phone:870-253-9616
Mailing Address - Fax:
Practice Address - Street 1:115 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-3498
Practice Address - Country:US
Practice Address - Phone:870-892-5615
Practice Address - Fax:870-892-2592
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165303OtherNABP