Provider Demographics
NPI:1629681903
Name:HARRELL, DAKOTA RYAN
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:RYAN
Last Name:HARRELL
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 1:1108 CLOVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3247
Mailing Address - Country:US
Mailing Address - Phone:318-771-1856
Mailing Address - Fax:
Practice Address - Street 1:3001 E TEXAS ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3207
Practice Address - Country:US
Practice Address - Phone:318-742-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist