Provider Demographics
NPI:1366514929
Name:CHRONISTER, MARK N (PD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:N
Last Name:CHRONISTER
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19 WALLEYE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-7283
Mailing Address - Country:US
Mailing Address - Phone:479-968-6655
Mailing Address - Fax:479-964-9280
Practice Address - Street 1:1808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2724
Practice Address - Country:US
Practice Address - Phone:479-964-9163
Practice Address - Fax:479-964-9280
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD05916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist