Provider Demographics
NPI:1497338420
Name:HARDAGE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HARDAGE
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 1:2202 HIGHWAY 128
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:AR
Mailing Address - Zip Code:71929-6595
Mailing Address - Country:US
Mailing Address - Phone:870-313-1406
Mailing Address - Fax:
Practice Address - Street 1:1910 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2203
Practice Address - Country:US
Practice Address - Phone:501-337-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPI22654183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPI22654OtherPHARMACY INTERN LICENSE