Provider Demographics
NPI:1225240880
Name:DOMANGUE, DEBRA GAIL (RPH)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:GAIL
Last Name:DOMANGUE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-6177
Mailing Address - Country:US
Mailing Address - Phone:985-868-5157
Mailing Address - Fax:
Practice Address - Street 1:1175 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4940
Practice Address - Country:US
Practice Address - Phone:985-446-3011
Practice Address - Fax:985-446-3011
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist