Provider Demographics
NPI:1942654603
Name:MALLARD, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:MALLARD
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 1:1 KMART PLZ
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-2850
Mailing Address - Country:US
Mailing Address - Phone:501-843-6265
Mailing Address - Fax:847-396-2761
Practice Address - Street 1:1 KMART PLZ
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2850
Practice Address - Country:US
Practice Address - Phone:501-843-6265
Practice Address - Fax:847-396-2761
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD07036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist