=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114588373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REGINALD BOUTTE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2019
-----------------------------------------------------
Last Update Date | 06/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 806 JEFFERSON TER
-----------------------------------------------------
City | NEW IBERIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70560-5727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-376-6868
-----------------------------------------------------
Fax | 337-376-6866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 806 JEFFERSON TER
-----------------------------------------------------
City | NEW IBERIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70560-5727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-376-6868
-----------------------------------------------------
Fax | 337-376-6866
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PST.016411
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------