Provider Demographics
NPI:1093129074
Name:THORNTON, CARESSA
Entity Type:Individual
Prefix:
First Name:CARESSA
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 MEMORIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-6539
Mailing Address - Country:US
Mailing Address - Phone:504-274-8643
Mailing Address - Fax:
Practice Address - Street 1:3082 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4354
Practice Address - Country:US
Practice Address - Phone:228-872-2646
Practice Address - Fax:228-818-5632
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12681183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist