Provider Demographics
NPI:1629353107
Name:MITCHELL, LAUREN MALOCH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MALOCH
Last Name:MITCHELL
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 1:795 COLUMBIA ROAD 258
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753
Mailing Address - Country:US
Mailing Address - Phone:870-696-2452
Mailing Address - Fax:
Practice Address - Street 1:237 MAIN ST
Practice Address - Street 2:
Practice Address - City:STAMPS
Practice Address - State:AR
Practice Address - Zip Code:71860-2827
Practice Address - Country:US
Practice Address - Phone:870-533-4311
Practice Address - Fax:870-533-2731
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist