Provider Demographics
NPI:1942776265
Name:MVERE, IMI
Entity Type:Individual
Prefix:
First Name:IMI
Middle Name:
Last Name:MVERE
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:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-0211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 HIGHWAY 167 N
Practice Address - Street 2:
Practice Address - City:BALD KNOB
Practice Address - State:AR
Practice Address - Zip Code:72010-4058
Practice Address - Country:US
Practice Address - Phone:501-724-2391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD146361835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD14636OtherARKANSAS STATE PHARMACIST LICENSE