Provider Demographics
NPI:1780833764
Name:BRIAN, SAM C JR
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:C
Last Name:BRIAN
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 1:104 S JONES ST
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-3251
Mailing Address - Country:US
Mailing Address - Phone:318-628-3303
Mailing Address - Fax:318-628-7122
Practice Address - Street 1:104 S JONES ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3251
Practice Address - Country:US
Practice Address - Phone:318-628-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1211001Medicaid
LA4185140001Medicare NSC