Provider Demographics
NPI:1710697149
Name:BROUSSARD, RYAN CHASE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:CHASE
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16665 MAHONEY RD
Mailing Address - Street 2:
Mailing Address - City:PRIDE
Mailing Address - State:LA
Mailing Address - Zip Code:70770-8712
Mailing Address - Country:US
Mailing Address - Phone:225-341-9901
Mailing Address - Fax:
Practice Address - Street 1:9960 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-6457
Practice Address - Country:US
Practice Address - Phone:225-341-9901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.024627183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist