Provider Demographics
NPI:1144569609
Name:WYNN, AUBREY BOOTH III (RPH MBA MHA)
Entity Type:Individual
Prefix:MR
First Name:AUBREY
Middle Name:BOOTH
Last Name:WYNN
Suffix:III
Gender:M
Credentials:RPH MBA MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 MANSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3125
Mailing Address - Country:US
Mailing Address - Phone:318-686-6311
Mailing Address - Fax:318-686-3999
Practice Address - Street 1:9250 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3125
Practice Address - Country:US
Practice Address - Phone:318-686-6311
Practice Address - Fax:318-686-3999
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist