Provider Demographics
NPI:1164946489
Name:THIBODAUX, JORDAN P (RPH)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:P
Last Name:THIBODAUX
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 1:999 ROBERT BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2009
Mailing Address - Country:US
Mailing Address - Phone:985-643-7894
Mailing Address - Fax:985-649-2183
Practice Address - Street 1:999 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2009
Practice Address - Country:US
Practice Address - Phone:985-643-7894
Practice Address - Fax:985-649-2183
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist