Healthcare Provider Details

I. General information

NPI: 1164509550
Provider Name (Legal Business Name): RONALD JOSEPH BROUSSARD PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 STAGG
BASILE LA
70515
US

IV. Provider business mailing address

PO BOX 426
BASILE LA
70515-0426
US

V. Phone/Fax

Practice location:
  • Phone: 337-432-6642
  • Fax: 337-432-6606
Mailing address:
  • Phone: 337-432-6642
  • Fax: 337-432-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8958
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: