Provider Demographics
NPI:1194829648
Name:SMITH, DEREL J (PD)
Entity Type:Individual
Prefix:DR
First Name:DEREL
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 BAYOU EST S
Mailing Address - Street 2:
Mailing Address - City:DES ALLEMANDS
Mailing Address - State:LA
Mailing Address - Zip Code:70030-3342
Mailing Address - Country:US
Mailing Address - Phone:985-758-2021
Mailing Address - Fax:
Practice Address - Street 1:12125 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-3000
Practice Address - Country:US
Practice Address - Phone:985-785-8772
Practice Address - Fax:985-785-8772
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1266884Medicaid