Healthcare Provider Details

I. General information

NPI: 1295216018
Provider Name (Legal Business Name): ANDREW MICHAEL FONTENOT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

5310 DESIARD ST LOT 5
MONROE LA
71203-4620
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4000
  • Fax:
Mailing address:
  • Phone: 337-852-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number022539
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: