Provider Demographics
NPI:1346241007
Name:BROUSSARD, MALCOLM J
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:J
Last Name:BROUSSARD
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 1:3388 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1700
Mailing Address - Country:US
Mailing Address - Phone:225-925-6481
Mailing Address - Fax:225-922-0316
Practice Address - Street 1:3388 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1700
Practice Address - Country:US
Practice Address - Phone:225-925-6481
Practice Address - Fax:225-922-0316
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist