1114437985 NPI number — PHYSICIAN COMP RX, LLC

Table of content: SAMUEL LIONEL MALDONADO III (NPI 1184422974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114437985 NPI number — PHYSICIAN COMP RX, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN COMP RX, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114437985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 E APPLEBY RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-417-0938
Provider Business Mailing Address Fax Number:
844-892-9379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 E APPLEBY RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-417-0938
Provider Business Practice Location Address Fax Number:
844-892-9379
Provider Enumeration Date:
10/06/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BEATY
Authorized Official First Name:
BLAIR
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
800-417-0938

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)