Provider Demographics
NPI:1124031158
Name:FLETCHER, RANDELL STEVAN (RPH)
Entity Type:Individual
Prefix:
First Name:RANDELL
Middle Name:STEVAN
Last Name:FLETCHER
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:PO BOX 69004
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-9004
Mailing Address - Country:US
Mailing Address - Phone:318-473-2888
Mailing Address - Fax:318-483-5020
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-2888
Practice Address - Fax:318-483-5020
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist