Provider Demographics
NPI:1568778934
Name:BOURGEOIS, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BOURGEOIS
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 1:38000 HWY 3089
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38000 HIGHWAY 3089
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-8596
Practice Address - Country:US
Practice Address - Phone:225-473-3918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10265183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist