Healthcare Provider Details

I. General information

NPI: 1740492974
Provider Name (Legal Business Name): CARRIE BANTA MIX CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13565 HOOPER RD
BATON ROUGE LA
70818-2912
US

IV. Provider business mailing address

17463 HEARTHWOOD DR
GREENWELL SPRINGS LA
70739-5311
US

V. Phone/Fax

Practice location:
  • Phone: 225-262-6200
  • Fax: 225-262-6578
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number7630
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: