Provider Demographics
NPI:1083097927
Name:PUGH, CHRISTOPHER JACOB
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JACOB
Last Name:PUGH
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:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-0632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1331 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-6370
Practice Address - Country:US
Practice Address - Phone:985-386-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.020630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist