Provider Demographics
NPI:1962040550
Name:GEORGE, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:GEORGE
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 1:315 N SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3838
Mailing Address - Country:US
Mailing Address - Phone:479-462-6165
Mailing Address - Fax:
Practice Address - Street 1:103 GREGORY PL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3211
Practice Address - Country:US
Practice Address - Phone:501-985-0822
Practice Address - Fax:501-985-3610
Is Sole Proprietor?:No
Enumeration Date:2019-12-15
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD127601835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist