Provider Demographics
NPI:1760797518
Name:INDOVINA, RICHARD MICHAEL JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:INDOVINA
Suffix:JR
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 1:1001 MOSS LN
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-2739
Mailing Address - Country:US
Mailing Address - Phone:504-737-7752
Mailing Address - Fax:
Practice Address - Street 1:3330 W ESPLANADE AVE S
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3454
Practice Address - Country:US
Practice Address - Phone:504-828-5071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15322183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist