Provider Demographics
NPI:1558713826
Name:SIMON, MITCHELL
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:SIMON
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 1:5823 WILLOW BREEZES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-3144
Mailing Address - Country:US
Mailing Address - Phone:337-499-4563
Mailing Address - Fax:
Practice Address - Street 1:1601 E NAPOLEON ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-3654
Practice Address - Country:US
Practice Address - Phone:337-626-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist