Provider Demographics
NPI:1750677126
Name:GAUTREAUX, ELMO CHARLES (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:ELMO
Middle Name:CHARLES
Last Name:GAUTREAUX
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13998 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70373-3009
Mailing Address - Country:US
Mailing Address - Phone:985-693-8662
Mailing Address - Fax:985-693-8867
Practice Address - Street 1:13998 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAROSE
Practice Address - State:LA
Practice Address - Zip Code:70373-3009
Practice Address - Country:US
Practice Address - Phone:985-693-8662
Practice Address - Fax:985-693-8867
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist