Provider Demographics
NPI:1124217054
Name:BAKER, BETHANY (PHARMD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:BAKER
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 1:243 CURTISS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2425
Mailing Address - Country:US
Mailing Address - Phone:318-456-6290
Mailing Address - Fax:
Practice Address - Street 1:2551 GREENWOOD RD STE 110
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3984
Practice Address - Country:US
Practice Address - Phone:318-631-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06006414390200000X
LAPST.020541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program