Provider Demographics
NPI:1083496178
Name:BOURQUE, ANDREA K (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 GORDON CROCKET DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5161
Mailing Address - Country:US
Mailing Address - Phone:337-230-2102
Mailing Address - Fax:337-334-3339
Practice Address - Street 1:913 THE BLVD
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-6134
Practice Address - Country:US
Practice Address - Phone:337-334-3399
Practice Address - Fax:337-334-3339
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.019587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist