Provider Demographics
NPI:1710295258
Name:MIXON, STANLEY RAY (RPH)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:RAY
Last Name:MIXON
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 1:8549 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-5425
Mailing Address - Country:US
Mailing Address - Phone:318-435-5139
Mailing Address - Fax:
Practice Address - Street 1:8549 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-5425
Practice Address - Country:US
Practice Address - Phone:318-435-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR042208183500000X
AL13610183500000X
LA10409183500000X
GA019726183500000X
MSE-05812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist