Basic Information
| Provider Information | |||||||||
| NPI: | 1336558188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOZEMAN | ||||||||
| FirstName: | ARDELL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMACY TECHNICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1589 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720181589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013033115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1718 OLD HOT SPRINGS HWY | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013153344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183700000X | PD06316 | AR | Y | Pharmacy Service Providers | Pharmacy Technician |
No ID Information.