Healthcare Provider Details

I. General information

NPI: 1467922591
Provider Name (Legal Business Name): TOMMY TRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2018
Last Update Date: 12/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 THE BLVD
RAYNE LA
70578-6219
US

IV. Provider business mailing address

123 MANCHESTER CIR
LAFAYETTE LA
70506-7822
US

V. Phone/Fax

Practice location:
  • Phone: 337-334-6611
  • Fax:
Mailing address:
  • Phone: 133-785-2547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST.022744
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: