Provider Demographics
NPI:1700135530
Name:MALLETT, AMY KNISS (PHARMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KNISS
Last Name:MALLETT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653
Mailing Address - Country:US
Mailing Address - Phone:870-265-2220
Mailing Address - Fax:
Practice Address - Street 1:401 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653
Practice Address - Country:US
Practice Address - Phone:870-265-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist