Provider Demographics
NPI:1790819639
Name:BROUILLETTE, GANNON G (RPH)
Entity Type:Individual
Prefix:MR
First Name:GANNON
Middle Name:G
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W LANDRY ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-2623
Mailing Address - Country:US
Mailing Address - Phone:337-344-6004
Mailing Address - Fax:337-942-8490
Practice Address - Street 1:1406 W LANDRY ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-2623
Practice Address - Country:US
Practice Address - Phone:337-942-2653
Practice Address - Fax:337-942-8490
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist