Provider Demographics
NPI:1558805929
Name:DEAN, DE'SHANAE RENAE
Entity Type:Individual
Prefix:
First Name:DE'SHANAE
Middle Name:RENAE
Last Name:DEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-2514
Mailing Address - Country:US
Mailing Address - Phone:225-382-0665
Mailing Address - Fax:
Practice Address - Street 1:220 N ALEXANDER AVE
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-2514
Practice Address - Country:US
Practice Address - Phone:225-382-0665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.021847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist