Provider Demographics
NPI:1235912874
Name:MCCOY, DAN'TREL TY'RIQUE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAN'TREL
Middle Name:TY'RIQUE
Last Name:MCCOY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 ASH ST
Mailing Address - Street 2:
Mailing Address - City:BOUTTE
Mailing Address - State:LA
Mailing Address - Zip Code:70039-3144
Mailing Address - Country:US
Mailing Address - Phone:504-274-6706
Mailing Address - Fax:
Practice Address - Street 1:1313 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-7000
Practice Address - Country:US
Practice Address - Phone:985-785-1753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.024912183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist