Provider Demographics
NPI:1992521439
Name:EMERSON, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:EMERSON
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 1:420 CARLSON ST
Mailing Address - Street 2:
Mailing Address - City:CENTERTON
Mailing Address - State:AR
Mailing Address - Zip Code:72719-8814
Mailing Address - Country:US
Mailing Address - Phone:479-412-8308
Mailing Address - Fax:
Practice Address - Street 1:1400 N WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4676
Practice Address - Country:US
Practice Address - Phone:479-268-9830
Practice Address - Fax:479-268-9831
Is Sole Proprietor?:No
Enumeration Date:2024-11-30
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT11092183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician