Provider Demographics
NPI:1356429476
Name:SMITH, PHIL GARY (PD)
Entity type:Individual
Prefix:
First Name:PHIL
Middle Name:GARY
Last Name:SMITH
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31382 TULOT RD
Mailing Address - Street 2:
Mailing Address - City:TRUMANN
Mailing Address - State:AR
Mailing Address - Zip Code:72472-8469
Mailing Address - Country:US
Mailing Address - Phone:870-483-2205
Mailing Address - Fax:
Practice Address - Street 1:421 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472-3116
Practice Address - Country:US
Practice Address - Phone:870-483-6391
Practice Address - Fax:870-483-2710
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR05888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR05888OtherARK PHARMACIST