Healthcare Provider Details

I. General information

NPI: 1720119761
Provider Name (Legal Business Name): JOHN JEROME HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9021 CAMERON ST
DUSON LA
70529
US

IV. Provider business mailing address

408 LEBESQUE RD
LAFAYETTE LA
70507-5106
US

V. Phone/Fax

Practice location:
  • Phone: 337-873-6182
  • Fax:
Mailing address:
  • Phone: 337-232-7127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9110
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: