1023484920 NPI number — DR. LATRISHA BROUSSARD PHARM D

Table of content: DR. LATRISHA BROUSSARD PHARM D (NPI 1023484920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023484920 NPI number — DR. LATRISHA BROUSSARD PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSARD
Provider First Name:
LATRISHA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023484920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 TULIP WOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71203-2477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-387-6023
Provider Business Mailing Address Fax Number:
319-387-6367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 LOUISVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-6655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-387-6023
Provider Business Practice Location Address Fax Number:
318-387-6367
Provider Enumeration Date:
08/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  017727 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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