Provider Demographics
NPI:1407594021
Name:BAXLEY, KARON DALE (PD)
Entity Type:Individual
Prefix:DR
First Name:KARON
Middle Name:DALE
Last Name:BAXLEY
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 1:1310 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-3007
Mailing Address - Country:US
Mailing Address - Phone:870-451-3683
Mailing Address - Fax:
Practice Address - Street 1:1200 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3645
Practice Address - Country:US
Practice Address - Phone:870-451-3683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD05716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist