Provider Demographics
NPI:1831791730
Name:MOORMAN, COLTON
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:
Last Name:MOORMAN
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 1:15603 BIRD MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72768-9091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 ATLANTA ST SE
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-9364
Practice Address - Country:US
Practice Address - Phone:479-787-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD13952183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist