Provider Demographics
NPI:1003166513
Name:DOHERTY, MONICA WILSON (PHARMD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:WILSON
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40363
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70835-0363
Mailing Address - Country:US
Mailing Address - Phone:214-223-3927
Mailing Address - Fax:
Practice Address - Street 1:285 W PINE ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-3310
Practice Address - Country:US
Practice Address - Phone:985-386-6132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18396183500000X
TX42739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist