1063554574 NPI number — RYAN M DARTEZ R.PH., MBA

Table of content: RYAN M DARTEZ R.PH., MBA (NPI 1063554574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063554574 NPI number — RYAN M DARTEZ R.PH., MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DARTEZ
Provider First Name:
RYAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.PH., MBA
Provider Gender Code:
M

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:
1063554574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
332 MILL POND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YOUNGSVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70592-5655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-278-3007
Provider Business Mailing Address Fax Number:
337-235-4570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70501-6905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-235-4578
Provider Business Practice Location Address Fax Number:
337-235-4570
Provider Enumeration Date:
02/12/2007

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:  15874 , 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)

  • Identifier: 1895997 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15874 . This is a "PHARMACIST LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com