Provider Demographics
NPI:1417264276
Name:VIDRINE, JESSICA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VIDRINE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:29403 GREENWELL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-6322
Mailing Address - Country:US
Mailing Address - Phone:225-603-1507
Mailing Address - Fax:
Practice Address - Street 1:34865 LA HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70706-0669
Practice Address - Country:US
Practice Address - Phone:225-665-2428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist