Provider Demographics
NPI:1639254402
Name:VAN, PEGGY G (RPH)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:G
Last Name:VAN
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 1:2824 PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-8189
Mailing Address - Country:US
Mailing Address - Phone:318-322-0875
Mailing Address - Fax:318-323-2298
Practice Address - Street 1:1209 N 18TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5429
Practice Address - Country:US
Practice Address - Phone:318-323-2242
Practice Address - Fax:318-323-2298
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist