Provider Demographics
NPI:1346528056
Name:MUTTERS, GORDON RAY (PD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:RAY
Last Name:MUTTERS
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 1:7700 HIGHWAY 271 S
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8028
Mailing Address - Country:US
Mailing Address - Phone:479-646-7875
Mailing Address - Fax:479-646-3090
Practice Address - Street 1:2507 MARKET TRCE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8677
Practice Address - Country:US
Practice Address - Phone:479-646-5505
Practice Address - Fax:479-646-3090
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR07041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist