Provider Demographics
NPI:1619285186
Name:CHERI, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:CHERI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15232 GEORGE ONEAL RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1507
Mailing Address - Country:US
Mailing Address - Phone:225-753-0805
Mailing Address - Fax:225-752-8360
Practice Address - Street 1:15232 GEORGE ONEAL RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1507
Practice Address - Country:US
Practice Address - Phone:225-753-0805
Practice Address - Fax:225-752-8360
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-18
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1260151Medicaid