Provider Demographics
NPI:1811598519
Name:BELLCOCK, ADAM TRISTAN
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:TRISTAN
Last Name:BELLCOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 BLUE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6354
Mailing Address - Country:US
Mailing Address - Phone:501-607-3269
Mailing Address - Fax:
Practice Address - Street 1:926 E COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-9400
Practice Address - Country:US
Practice Address - Phone:870-642-6921
Practice Address - Fax:870-642-7155
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14621183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist