Provider Demographics
NPI:1124573795
Name:PETITJEAN, ELMO EMILE (RPH)
Entity Type:Individual
Prefix:
First Name:ELMO
Middle Name:EMILE
Last Name:PETITJEAN
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 1:216 NOTTING HILL WAY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5417
Mailing Address - Country:US
Mailing Address - Phone:337-366-4079
Mailing Address - Fax:
Practice Address - Street 1:806 ODD FELLOWS RD
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2214
Practice Address - Country:US
Practice Address - Phone:337-783-8316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist