Healthcare Provider Details

I. General information

NPI: 1487783171
Provider Name (Legal Business Name): JEANNE BOURQUE MAYLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 HIGHWAY 3125
GRAMERCY LA
70052
US

IV. Provider business mailing address

PO BOX 1511
GRAMERCY LA
70052-1511
US

V. Phone/Fax

Practice location:
  • Phone: 225-869-3651
  • Fax: 225-869-8826
Mailing address:
  • Phone: 225-869-3651
  • Fax: 225-869-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16714
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: