MEDICARE: TAMARA PRINCE BREAUX PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	018203	LA

General Provider Information

NPI Number	:	1922398296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA PRINCE BREAUX PHARMD

Provider Business Mailing Address
First Line	:	3895 HOBBINS RD
Second Line	:
City	:	VINTON
State	:	LA
Zip	:	70668-5407
Country	:	US
Telephone Number	:	337-660-1542
Fax Number	:

Provider Business Practice Location Address
First Line	:	2825 RYAN ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-7329
Country	:	US
Telephone Number	:	337-434-1590
Fax Number	:	337-437-7639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2011
Last Update Date	:	04/07/2011

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