Provider Demographics
NPI:1780013458
Name:DEGENNARO, JEAN (RPH)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:DEGENNARO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 YORK DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2443
Mailing Address - Country:US
Mailing Address - Phone:318-614-1763
Mailing Address - Fax:
Practice Address - Street 1:2735 BEENE BLVD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5491
Practice Address - Country:US
Practice Address - Phone:318-678-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist