Provider Demographics
NPI:1295041929
Name:OCTAVE, BRIDGET ANNE
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ANNE
Last Name:OCTAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346-0069
Mailing Address - Country:US
Mailing Address - Phone:225-473-3537
Mailing Address - Fax:
Practice Address - Street 1:12506 HIGHWAY 73
Practice Address - Street 2:
Practice Address - City:GEISMAR
Practice Address - State:LA
Practice Address - Zip Code:70734-3209
Practice Address - Country:US
Practice Address - Phone:225-677-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist