Provider Demographics
NPI:1437263712
Name:BROUSSARD, GERALD (RPH)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:BROUSSARD
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 1:17724 LOUISIANA HIGHWAY 331
Mailing Address - Street 2:
Mailing Address - City:ERATH
Mailing Address - State:LA
Mailing Address - Zip Code:70533
Mailing Address - Country:US
Mailing Address - Phone:337-937-8416
Mailing Address - Fax:337-364-0465
Practice Address - Street 1:805 CENTER ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-5505
Practice Address - Country:US
Practice Address - Phone:337-364-0464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist