Provider Demographics
NPI:1770161911
Name:MIDDLETON, MARCO RENELL SR
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:RENELL
Last Name:MIDDLETON
Suffix:SR
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 1:249 CARLA DR
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:AR
Mailing Address - Zip Code:72029-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:AR
Practice Address - Zip Code:72029-2717
Practice Address - Country:US
Practice Address - Phone:870-747-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15022183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist