Provider Demographics
NPI:1083815484
Name:MAYVILLE, GERADINE (PD)
Entity Type:Individual
Prefix:MRS
First Name:GERADINE
Middle Name:
Last Name:MAYVILLE
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 HUEY P LONG AVE
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-6125
Mailing Address - Country:US
Mailing Address - Phone:504-362-5106
Mailing Address - Fax:
Practice Address - Street 1:5400 TCHOUPITOULAS ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-2020
Practice Address - Country:US
Practice Address - Phone:504-899-3992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10594183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA10594OtherPHARMACIST