Provider Demographics
NPI:1679859375
Name:HEADLEY, RONALD LYNN (PD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:LYNN
Last Name:HEADLEY
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1664 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4508
Mailing Address - Country:US
Mailing Address - Phone:501-467-8197
Mailing Address - Fax:501-467-8662
Practice Address - Street 1:308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-3737
Practice Address - Country:US
Practice Address - Phone:501-467-8197
Practice Address - Fax:501-467-8662
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist