Provider Demographics
NPI:1356820120
Name:CANTRELL, RAYLEN DOUGLAS
Entity Type:Individual
Prefix:
First Name:RAYLEN
Middle Name:DOUGLAS
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 W 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-5053
Mailing Address - Country:US
Mailing Address - Phone:870-850-6084
Mailing Address - Fax:
Practice Address - Street 1:2503 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-5053
Practice Address - Country:US
Practice Address - Phone:870-850-6084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-12
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist