Provider Demographics
NPI:1275820516
Name:MIRE, RANDY (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:MIRE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RESERVE
Mailing Address - State:LA
Mailing Address - Zip Code:70084-6001
Mailing Address - Country:US
Mailing Address - Phone:985-536-3957
Mailing Address - Fax:985-536-2231
Practice Address - Street 1:139 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-6001
Practice Address - Country:US
Practice Address - Phone:985-536-3957
Practice Address - Fax:985-536-2231
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist