Basic Information
| Provider Information | |||||||||
| NPI: | 1962002782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAYTON | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | PAUL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 WALLEYE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728027298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797471409 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2109 W MAIN | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794989540 | ||||||||
| FaxNumber: | 4794989543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2020 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD08199 | AR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.