Provider Demographics
NPI:1295042877
Name:MULLICAN, JEFFERY SCOTT (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:SCOTT
Last Name:MULLICAN
Suffix:
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 1:916 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:DE RIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-2816
Mailing Address - Country:US
Mailing Address - Phone:337-462-2019
Mailing Address - Fax:
Practice Address - Street 1:916 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-2816
Practice Address - Country:US
Practice Address - Phone:337-462-2019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist