Provider Demographics
NPI:1689359390
Name:HARRIS, FRED WILLIAM (PD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:WILLIAM
Last Name:HARRIS
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 1:1430 W 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-3339
Mailing Address - Country:US
Mailing Address - Phone:870-602-1777
Mailing Address - Fax:870-887-2968
Practice Address - Street 1:1430 W 1ST ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-3339
Practice Address - Country:US
Practice Address - Phone:870-602-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06411183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist