Provider Demographics
NPI:1124362579
Name:EVERETT, ALAN DALE (RPH)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:DALE
Last Name:EVERETT
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 1:1613 GLENN BLVD SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-3531
Mailing Address - Country:US
Mailing Address - Phone:256-845-0128
Mailing Address - Fax:
Practice Address - Street 1:1613 GLENN BLVD SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3531
Practice Address - Country:US
Practice Address - Phone:256-845-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist