Provider Demographics
NPI:1801913611
Name:ETCHASON, BOBBY LEAVORN (RPH)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:LEAVORN
Last Name:ETCHASON
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 1:4446 KERTH CIRCLE XING
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3131
Mailing Address - Country:US
Mailing Address - Phone:314-892-1792
Mailing Address - Fax:636-282-0816
Practice Address - Street 1:1253 WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2142
Practice Address - Country:US
Practice Address - Phone:636-282-0803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029042183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist