Provider Demographics
NPI:1578854410
Name:BOURGEOIS, DWAYNE PAUL
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:PAUL
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 1:14231 SANTA FE TRL
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4456
Mailing Address - Country:US
Mailing Address - Phone:225-677-6999
Mailing Address - Fax:225-819-8168
Practice Address - Street 1:2159 STARING LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1038
Practice Address - Country:US
Practice Address - Phone:225-766-1107
Practice Address - Fax:225-819-8168
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist