Provider Demographics
NPI:1619018793
Name:MACK, ROBERT GARY II (BACHELOR)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GARY
Last Name:MACK
Suffix:II
Gender:M
Credentials:BACHELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 EDGEWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72936
Mailing Address - Country:US
Mailing Address - Phone:479-414-1190
Mailing Address - Fax:
Practice Address - Street 1:2712 EDGEWATER DRIVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:AR
Practice Address - Zip Code:72936
Practice Address - Country:US
Practice Address - Phone:479-414-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1002664171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor