Provider Demographics
NPI:1235412909
Name:HUBER, BRUCE WALLACE
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WALLACE
Last Name:HUBER
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 1:1315 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5233
Mailing Address - Country:US
Mailing Address - Phone:318-801-5023
Mailing Address - Fax:
Practice Address - Street 1:1315 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5233
Practice Address - Country:US
Practice Address - Phone:318-801-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist