Provider Demographics
NPI:1922147834
Name:DEDMON, DANIELLE LOREN (PD)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:LOREN
Last Name:DEDMON
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 MASSARD RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-5042
Mailing Address - Country:US
Mailing Address - Phone:479-551-2840
Mailing Address - Fax:479-551-2492
Practice Address - Street 1:6210 MASSARD RD STE 104
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-5042
Practice Address - Country:US
Practice Address - Phone:479-551-2840
Practice Address - Fax:918-962-5750
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08844183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty