Provider Demographics
NPI:1184302606
Name:WINGFIELD, JACOB A (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 W HUNTINGTON DR APT 7207
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1713
Mailing Address - Country:US
Mailing Address - Phone:501-765-1230
Mailing Address - Fax:
Practice Address - Street 1:2110 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3246
Practice Address - Country:US
Practice Address - Phone:479-277-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist