Provider Demographics
NPI:1700561644
Name:VAN ENK, ALEXANDRIA MICHELLE
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MICHELLE
Last Name:VAN ENK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BETSY LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4910
Mailing Address - Country:US
Mailing Address - Phone:501-606-2634
Mailing Address - Fax:
Practice Address - Street 1:14820 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4244
Practice Address - Country:US
Practice Address - Phone:501-868-6324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD161943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy