Provider Demographics
NPI:1194031617
Name:BOURGEOIS, LANCE
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:BOURGEOIS
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 1:4600 WESTBANK EXPY
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3065
Mailing Address - Country:US
Mailing Address - Phone:504-340-6337
Mailing Address - Fax:
Practice Address - Street 1:4600 WESTBANK EXPY
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3065
Practice Address - Country:US
Practice Address - Phone:504-340-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-21
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14834183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist