Provider Demographics
NPI:1780228346
Name:THE FUNCTIONAL PHARMACIST INC
Entity Type:Organization
Organization Name:THE FUNCTIONAL PHARMACIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:870-265-6603
Mailing Address - Street 1:401 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1731
Mailing Address - Country:US
Mailing Address - Phone:870-265-6603
Mailing Address - Fax:
Practice Address - Street 1:401 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1731
Practice Address - Country:US
Practice Address - Phone:870-265-6603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-06
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center