Provider Demographics
NPI:1629502042
Name:BEENE, JEFFERY TODD (PD)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:TODD
Last Name:BEENE
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MARIANNA ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-5523
Mailing Address - Country:US
Mailing Address - Phone:318-341-1119
Mailing Address - Fax:
Practice Address - Street 1:402 E DARROW ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3512
Practice Address - Country:US
Practice Address - Phone:318-574-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.015625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist