Healthcare Provider Details

I. General information

NPI: 1053667030
Provider Name (Legal Business Name): EDWIN G. BLANCHE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PLANK ROAD
SAINT JOSEPH LA
71366
US

IV. Provider business mailing address

PO BOX 5
SAINT JOSEPH LA
71366-0005
US

V. Phone/Fax

Practice location:
  • Phone: 318-766-4563
  • Fax: 318-766-4522
Mailing address:
  • Phone: 318-766-4563
  • Fax: 318-766-4522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10263
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: