Provider Demographics
NPI:1407984164
Name:BENOIT, BRYAN E
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:E
Last Name:BENOIT
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ED
Other - Middle Name:
Other - Last Name:BENOIT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:719 W GLORIA SWITCH RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-2313
Mailing Address - Country:US
Mailing Address - Phone:337-896-3813
Mailing Address - Fax:
Practice Address - Street 1:913 THE BLVD
Practice Address - Street 2:
Practice Address - City:RAYNE
Practice Address - State:LA
Practice Address - Zip Code:70578-6134
Practice Address - Country:US
Practice Address - Phone:337-334-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist