Provider Demographics
NPI:1649394057
Name:BOURG, CHERYL LARRIEU (RPH)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LARRIEU
Last Name:BOURG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18235 BEL MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-6033
Mailing Address - Country:US
Mailing Address - Phone:225-752-5909
Mailing Address - Fax:225-753-7886
Practice Address - Street 1:LSU STUDENT HEALTH CENTER PHARMACY
Practice Address - Street 2:INFIRMARY ROAD, LSU
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70803
Practice Address - Country:US
Practice Address - Phone:225-578-5651
Practice Address - Fax:225-578-7684
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist