Provider Demographics
NPI:1457031916
Name:BRUNSON, GAVIN
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SAIA MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72857-9029
Mailing Address - Country:US
Mailing Address - Phone:318-278-2176
Mailing Address - Fax:
Practice Address - Street 1:230 E MARKET ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-9069
Practice Address - Country:US
Practice Address - Phone:479-754-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist