Provider Demographics
NPI:1659630861
Name:LACOUR, LISA FORTENBERRY (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FORTENBERRY
Last Name:LACOUR
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 1:42342 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-2179
Mailing Address - Country:US
Mailing Address - Phone:985-320-5211
Mailing Address - Fax:225-294-0241
Practice Address - Street 1:1812 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2945
Practice Address - Country:US
Practice Address - Phone:985-345-4767
Practice Address - Fax:985-345-4768
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist