1497476204 NPI number — JAMES MACKENZIE DAUGHERTY PHARM.D

Table of content: JAMES MACKENZIE DAUGHERTY PHARM.D (NPI 1497476204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497476204 NPI number — JAMES MACKENZIE DAUGHERTY PHARM.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
JAMES
Provider Middle Name:
MACKENZIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D
Provider Gender Code:
M

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:
1497476204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1202 E 21ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUTTGART
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72160-6910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-830-8565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 COURT SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DE WITT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72042-2057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-946-4211
Provider Business Practice Location Address Fax Number:
870-946-1011
Provider Enumeration Date:
09/09/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PD16216 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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