Provider Demographics
NPI:1689114241
Name:PRUDHOMME, REBECCA BROCK (PHARMD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:BROCK
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5619
Mailing Address - Country:US
Mailing Address - Phone:225-206-2533
Mailing Address - Fax:
Practice Address - Street 1:6130 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5619
Practice Address - Country:US
Practice Address - Phone:225-206-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist