Provider Demographics
NPI:1043604416
Name:MCINNIS, LATIS (RPH)
Entity Type:Individual
Prefix:
First Name:LATIS
Middle Name:
Last Name:MCINNIS
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 1:366 LEIGH LN
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-5414
Mailing Address - Country:US
Mailing Address - Phone:318-422-4244
Mailing Address - Fax:
Practice Address - Street 1:366 LEIGH LN
Practice Address - Street 2:
Practice Address - City:STONEWALL
Practice Address - State:LA
Practice Address - Zip Code:71078-5414
Practice Address - Country:US
Practice Address - Phone:318-422-4244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16562183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist