Provider Demographics
NPI:1679625800
Name:PELLEGRIN, DEAN PATRICK
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:PATRICK
Last Name:PELLEGRIN
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 1:6096 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70364-1808
Mailing Address - Country:US
Mailing Address - Phone:985-876-2584
Mailing Address - Fax:985-876-5050
Practice Address - Street 1:6096 W PARK AVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-1808
Practice Address - Country:US
Practice Address - Phone:985-876-2584
Practice Address - Fax:985-876-5050
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1205745Medicaid
1905984OtherNCPDP
LA1094550001Medicare ID - Type Unspecified