Provider Demographics
NPI:1417579798
Name:STEWART, ALVIN RAY SR (RPH)
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:RAY
Last Name:STEWART
Suffix:SR
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 1:696 CEDAR SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-5710
Mailing Address - Country:US
Mailing Address - Phone:504-722-3326
Mailing Address - Fax:
Practice Address - Street 1:696 CEDAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-5710
Practice Address - Country:US
Practice Address - Phone:504-722-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13871183500000X
MST-010898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty