Healthcare Provider Details

I. General information

NPI: 1194946939
Provider Name (Legal Business Name): MRS. SUSAN PORTEOUS CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 LA HWY 3125
GRAMERCY LA
70052
US

IV. Provider business mailing address

P.O. BOX 1946
LAPLACE LA
70069
US

V. Phone/Fax

Practice location:
  • Phone: 225-869-8695
  • Fax:
Mailing address:
  • Phone: 985-651-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15026
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: