Provider Demographics
NPI:1568059590
Name:BOURGOYNE, LANCE
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:BOURGOYNE
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 1:5131 ODONOVAN DR STE 402
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4792
Mailing Address - Country:US
Mailing Address - Phone:225-765-8140
Mailing Address - Fax:225-374-0271
Practice Address - Street 1:5131 ODONOVAN DR STE 402
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4792
Practice Address - Country:US
Practice Address - Phone:225-765-8140
Practice Address - Fax:225-374-0271
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0139691835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist