Provider Demographics
NPI:1619282019
Name:MUSSO, CHARLES P (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:P
Last Name:MUSSO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4752 HIGHWAY 311
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2810
Mailing Address - Country:US
Mailing Address - Phone:985-879-2440
Mailing Address - Fax:985-879-2967
Practice Address - Street 1:4752 HIGHWAY 311
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2810
Practice Address - Country:US
Practice Address - Phone:985-879-2440
Practice Address - Fax:985-879-2967
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist