Provider Demographics
NPI:1538475991
Name:LANE, KESA (RPH)
Entity Type:Individual
Prefix:
First Name:KESA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-3546
Mailing Address - Country:US
Mailing Address - Phone:337-463-7210
Mailing Address - Fax:337-462-0930
Practice Address - Street 1:610 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-3546
Practice Address - Country:US
Practice Address - Phone:337-463-7210
Practice Address - Fax:337-462-0930
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15771183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist