Provider Demographics
NPI:1154606614
Name:BRYAN SCOTT POLLOCK
Entity type:Organization
Organization Name:BRYAN SCOTT POLLOCK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-856-2890
Mailing Address - Street 1:101 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8827
Mailing Address - Country:US
Mailing Address - Phone:870-856-2890
Mailing Address - Fax:870-856-2891
Practice Address - Street 1:101 CHURCH ST
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:AR
Practice Address - Zip Code:72542-8827
Practice Address - Country:US
Practice Address - Phone:870-856-2890
Practice Address - Fax:870-856-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR206643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0423791OtherNCPDP PROVIDER IDENTIFICATION NUMBER