Provider Demographics
NPI:1447033246
Name:BETHELL, COURTNEY BLAKE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BLAKE
Last Name:BETHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HIGHWAY 64 E
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-7414
Mailing Address - Country:US
Mailing Address - Phone:870-238-7146
Mailing Address - Fax:870-238-7162
Practice Address - Street 1:800 HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-7414
Practice Address - Country:US
Practice Address - Phone:870-238-7146
Practice Address - Fax:870-238-7162
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty