Provider Demographics
NPI:1164509550
Name:BROUSSARD, RONALD JOSEPH (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JOSEPH
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:BASILE
Mailing Address - State:LA
Mailing Address - Zip Code:70515-0426
Mailing Address - Country:US
Mailing Address - Phone:337-432-6642
Mailing Address - Fax:337-432-6606
Practice Address - Street 1:3131 STAGG
Practice Address - Street 2:
Practice Address - City:BASILE
Practice Address - State:LA
Practice Address - Zip Code:70515
Practice Address - Country:US
Practice Address - Phone:337-432-6642
Practice Address - Fax:337-432-6606
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1262927Medicaid
LA1262927Medicaid