MEDICARE: MICHAEL M PROVOST RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	15527	LA

General Provider Information

NPI Number	:	1669755302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL M PROVOST RPH

Provider Business Mailing Address
First Line	:	755 OLE HIGHWAY 15 LOT 92
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-1413
Country	:	US
Telephone Number	:	318-680-3590
Fax Number	:

Provider Business Practice Location Address
First Line	:	755 OLE HIGHWAY 15 LOT 92
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-1413
Country	:	US
Telephone Number	:	318-680-3590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	09/20/2011

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