Provider Demographics
NPI:1588112361
Name:WILLIS, LAUREN GASTON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:GASTON
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHARMD
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 1410
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1410
Mailing Address - Country:US
Mailing Address - Phone:479-437-6023
Mailing Address - Fax:614-652-4771
Practice Address - Street 1:136 HEALTH PARK DR
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-9072
Practice Address - Country:US
Practice Address - Phone:479-437-6023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist