Provider Demographics
NPI:1871735456
Name:PHILLIPS, MARY CHARLOTTE (RPH)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CHARLOTTE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9044 HIDDEN VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:AR
Mailing Address - Zip Code:72821-8869
Mailing Address - Country:US
Mailing Address - Phone:479-468-2149
Mailing Address - Fax:
Practice Address - Street 1:7301 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4100
Practice Address - Country:US
Practice Address - Phone:479-314-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD7661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist