Provider Demographics
NPI:1114232253
Name:DAIGREPONT, DARRELL (RPH)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:DAIGREPONT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 JACKSON STREET EXT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2708
Mailing Address - Country:US
Mailing Address - Phone:318-448-9340
Mailing Address - Fax:318-448-9505
Practice Address - Street 1:4444 JACKSON STREET EXT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2708
Practice Address - Country:US
Practice Address - Phone:318-448-9340
Practice Address - Fax:318-448-9505
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist