Healthcare Provider Details

I. General information

NPI: 1376954750
Provider Name (Legal Business Name): IVAN LANDRY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E MAIN ST
BROUSSARD LA
70518-4616
US

IV. Provider business mailing address

103 E MAIN ST
BROUSSARD LA
70518-4616
US

V. Phone/Fax

Practice location:
  • Phone: 337-839-8880
  • Fax: 337-839-8881
Mailing address:
  • Phone: 337-839-8880
  • Fax: 337-839-8881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST.014938
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: