Provider Demographics
NPI:1376710640
Name:SMITH, MARK DAMRON (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAMRON
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4001
Mailing Address - Country:US
Mailing Address - Phone:806-791-0972
Mailing Address - Fax:806-791-1784
Practice Address - Street 1:3405 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4001
Practice Address - Country:US
Practice Address - Phone:806-791-0972
Practice Address - Fax:806-791-1784
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist