Provider Demographics
NPI:1356632699
Name:BUILDER, THERESA PATE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:PATE
Last Name:BUILDER
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 1:223 CLARA DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4716
Mailing Address - Country:US
Mailing Address - Phone:225-266-1191
Mailing Address - Fax:
Practice Address - Street 1:2152 S SHERWOOD FOREST BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8327
Practice Address - Country:US
Practice Address - Phone:225-272-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist