Provider Demographics
NPI:1720310071
Name:BRASHEAR, DEDRIA (RPH)
Entity Type:Individual
Prefix:
First Name:DEDRIA
Middle Name:
Last Name:BRASHEAR
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-2002
Mailing Address - Country:US
Mailing Address - Phone:318-259-7334
Mailing Address - Fax:
Practice Address - Street 1:500 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2002
Practice Address - Country:US
Practice Address - Phone:318-259-7334
Practice Address - Fax:318-259-3013
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1810509Medicaid