Provider Demographics
NPI:1083020838
Name:NETHERY, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:NETHERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-3700
Mailing Address - Country:US
Mailing Address - Phone:985-386-2421
Mailing Address - Fax:985-386-5988
Practice Address - Street 1:1100 W PINE ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-3700
Practice Address - Country:US
Practice Address - Phone:985-386-2421
Practice Address - Fax:985-386-5988
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA160048183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist