Provider Demographics
NPI:1982469847
Name:FORMBY, MILLARD III
Entity Type:Individual
Prefix:
First Name:MILLARD
Middle Name:
Last Name:FORMBY
Suffix:III
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 1:206 GEORGIAN TER
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-3010
Mailing Address - Country:US
Mailing Address - Phone:903-276-1262
Mailing Address - Fax:
Practice Address - Street 1:3710 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1934
Practice Address - Country:US
Practice Address - Phone:870-773-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist