Healthcare Provider Details

I. General information

NPI: 1255631958
Provider Name (Legal Business Name): ANN MARIE NICOLE MOODY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. ANN MARIE NICOLE BURAS

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E MAIN ST P O DRAWER 1003
OAK GROVE LA
71263-2552
US

IV. Provider business mailing address

411 E MAIN ST P O DRAWER 1003
OAK GROVE LA
71263-2552
US

V. Phone/Fax

Practice location:
  • Phone: 318-428-4205
  • Fax: 318-428-4207
Mailing address:
  • Phone: 318-428-4205
  • Fax: 318-428-4207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18288
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: