Provider Demographics
NPI:1104045657
Name:STEPHENS, RANDY CORNELIOUS (RPH)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:CORNELIOUS
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 WESTERDALE DR
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-4216
Mailing Address - Country:US
Mailing Address - Phone:281-533-9497
Mailing Address - Fax:
Practice Address - Street 1:5007 WESTERDALE DR
Practice Address - Street 2:
Practice Address - City:FULSHEAR
Practice Address - State:TX
Practice Address - Zip Code:77441-4216
Practice Address - Country:US
Practice Address - Phone:281-533-9497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24638183500000X
OK9851183500000X
AZ7400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist