1063768547 NPI number — JANA GAIL TREECE PHARMD

Table of content: (NPI 1285702985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063768547 NPI number — JANA GAIL TREECE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TREECE
Provider First Name:
JANA
Provider Middle Name:
GAIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALSH
Provider Other First Name:
JANA
Provider Other Middle Name:
TREECE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063768547
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10155 WESTWIND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71106-8290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-773-5520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3710 YOUREE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-841-6416
Provider Business Practice Location Address Fax Number:
318-769-0809
Provider Enumeration Date:
08/02/2012

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:  PST.019812 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: 37023 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PST.019812 . This is a "LOUISIANA BOARD OF PHARMACY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 37023 . This is a "TENNESSEE BOARD OF PHARMACY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 2305841 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".