Provider Demographics
NPI:1083386379
Name:BOUDREAUX, DREW RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:RYAN
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAKESHORE DR APT G303
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6087
Mailing Address - Country:US
Mailing Address - Phone:228-697-3690
Mailing Address - Fax:
Practice Address - Street 1:1000 HUGH WARD BLVD
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6600
Practice Address - Country:US
Practice Address - Phone:601-992-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist