Healthcare Provider Details

I. General information

NPI: 1871102939
Provider Name (Legal Business Name): PATRICIA WADE DANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 CYPRESS ST
WEST MONROE LA
71291-5337
US

IV. Provider business mailing address

733 DUMMY LINE RD
RAYVILLE LA
71269-7767
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-3142
  • Fax:
Mailing address:
  • Phone: 318-376-2136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number015496
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: