Provider Demographics
NPI:1003317322
Name:BORDELON, PAUL ANTOINE (RPH)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTOINE
Last Name:BORDELON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-6041
Mailing Address - Country:US
Mailing Address - Phone:225-356-0654
Mailing Address - Fax:
Practice Address - Street 1:6920 PLANK RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70811-6041
Practice Address - Country:US
Practice Address - Phone:225-356-0654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.013301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPST.013301OtherLOUISIANA BOARD OF PHARMACY