Provider Demographics
NPI:1235369562
Name:BROUSSARD, EDWARD JAMES JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JAMES
Last Name:BROUSSARD
Suffix:JR
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 1:411 HARRELL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4822
Mailing Address - Country:US
Mailing Address - Phone:337-984-9660
Mailing Address - Fax:337-984-9660
Practice Address - Street 1:411 HARRELL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4822
Practice Address - Country:US
Practice Address - Phone:337-984-9660
Practice Address - Fax:337-984-9660
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist