Provider Demographics
NPI:1346350923
Name:SMITH, MICHAEL DEAN (PD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 S ENID AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4534
Mailing Address - Country:US
Mailing Address - Phone:479-968-1050
Mailing Address - Fax:479-968-1557
Practice Address - Street 1:3103 W MAIN PL
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3360
Practice Address - Country:US
Practice Address - Phone:479-968-1050
Practice Address - Fax:479-968-1557
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist