Provider Demographics
NPI:1346643665
Name:WAGUESPACK, LISA H (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:H
Last Name:WAGUESPACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:H
Other - Last Name:HEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1625 ST. MARY STREET
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 ST, MARY STREET
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301
Practice Address - Country:US
Practice Address - Phone:985-493-6981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11771183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist