1578149951 NPI number — LANSDELL FAMILY CLINIC PLLC

Table of content: MICHAEL M WYMAN PHARM.D. (NPI 1760459804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578149951 NPI number — LANSDELL FAMILY CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANSDELL FAMILY CLINIC PLLC
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:
1578149951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 E COLLIN RAYE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DE QUEEN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71832-8048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-584-1053
Provider Business Mailing Address Fax Number:
870-584-2087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 W MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOCKESBURG
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71846-9621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-289-2076
Provider Business Practice Location Address Fax Number:
870-289-2043
Provider Enumeration Date:
03/24/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LANSDELL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
870-584-1053

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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