Provider Demographics
NPI:1508155508
Name:BONVILLAIN, KIBRY WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:KIBRY
Middle Name:WAYNE
Last Name:BONVILLAIN
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 1:600 ROUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4556
Mailing Address - Country:US
Mailing Address - Phone:985-381-4899
Mailing Address - Fax:985-853-2091
Practice Address - Street 1:600 ROUSSELL ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-381-4899
Practice Address - Fax:985-853-2091
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist