Provider Demographics
NPI:1104484971
Name:GILBREATH, AUSTIN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:GILBREATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-0278
Mailing Address - Country:US
Mailing Address - Phone:870-994-7377
Mailing Address - Fax:870-994-7399
Practice Address - Street 1:970D ASH FLAT DR
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9533
Practice Address - Country:US
Practice Address - Phone:870-994-7377
Practice Address - Fax:870-994-7399
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR015313336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100176407Medicaid