Healthcare Provider Details

I. General information

NPI: 1780056473
Provider Name (Legal Business Name): DUSTY FALLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 N FRANKLIN ST
BASTROP LA
71220-3846
US

IV. Provider business mailing address

PO BOX 792
BASTROP LA
71221-0792
US

V. Phone/Fax

Practice location:
  • Phone: 318-239-8045
  • Fax: 318-556-8451
Mailing address:
  • Phone: 318-283-8887
  • Fax: 318-281-2559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number021044
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: