Provider Demographics
NPI:1164941142
Name:BOSTANIAN, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BOSTANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 JANICE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065
Mailing Address - Country:US
Mailing Address - Phone:504-275-8699
Mailing Address - Fax:
Practice Address - Street 1:13001 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039-3051
Practice Address - Country:US
Practice Address - Phone:985-785-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist