Provider Demographics
NPI:1255438917
Name:EWALD, CONNIE STROUD (RPH)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:STROUD
Last Name:EWALD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 STONERIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1460
Mailing Address - Country:US
Mailing Address - Phone:903-838-9647
Mailing Address - Fax:
Practice Address - Street 1:5001 N STATE LINE AVE STE C
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2962
Practice Address - Country:US
Practice Address - Phone:800-785-4197
Practice Address - Fax:877-737-9135
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27433183500000X
AR9347183500000X
TN11840183500000X
NE12236183500000X
MI033937183500000X
LA17557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist