Provider Demographics
NPI:1558578161
Name:IVEY, WILLIAM
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:IVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 WEEPING WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-6283
Mailing Address - Country:US
Mailing Address - Phone:337-344-9575
Mailing Address - Fax:
Practice Address - Street 1:110 W FIRST ST
Practice Address - Street 2:SUITE B
Practice Address - City:DUSON
Practice Address - State:LA
Practice Address - Zip Code:70529-6100
Practice Address - Country:US
Practice Address - Phone:337-935-6439
Practice Address - Fax:337-662-5556
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist