Provider Demographics
NPI:1659852242
Name:FONTENOT, CLINT
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535-2902
Mailing Address - Country:US
Mailing Address - Phone:337-457-4827
Mailing Address - Fax:337-457-4223
Practice Address - Street 1:1800 W LAUREL AVE
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-2902
Practice Address - Country:US
Practice Address - Phone:337-457-4827
Practice Address - Fax:337-457-4223
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16780183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist