Provider Demographics
NPI:1477964443
Name:DANIEL, KANETHIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:KANETHIA
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N SERVICE RD E
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2917
Mailing Address - Country:US
Mailing Address - Phone:318-251-0392
Mailing Address - Fax:
Practice Address - Street 1:1201 N SERVICE RD E
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2917
Practice Address - Country:US
Practice Address - Phone:318-251-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist