Provider Demographics
NPI:1376681577
Name:DUFOUR, KEVIN MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:DUFOUR
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 1:116 BARNES CT
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-8635
Mailing Address - Country:US
Mailing Address - Phone:504-433-1175
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:N116
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6185
Practice Address - Fax:504-349-6188
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1268615Medicaid