Provider Demographics
NPI:1023636610
Name:WADLEY, DOMONIQUE DESHEA (PHARMD)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:DESHEA
Last Name:WADLEY
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 1:208 LACROSSE ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-9553
Mailing Address - Country:US
Mailing Address - Phone:501-655-2933
Mailing Address - Fax:
Practice Address - Street 1:998 SHADY GROVE RD STE 1H
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-8094
Practice Address - Country:US
Practice Address - Phone:501-262-5400
Practice Address - Fax:501-262-5404
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist