Provider Demographics
NPI:1619257912
Name:THIBODEAUX, ANDREA B (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:B
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 S LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-6303
Mailing Address - Country:US
Mailing Address - Phone:337-364-1368
Mailing Address - Fax:866-569-0767
Practice Address - Street 1:939 S LEWIS ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-6303
Practice Address - Country:US
Practice Address - Phone:337-364-1368
Practice Address - Fax:866-569-0767
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist