Provider Demographics
NPI:1821303785
Name:DAIGLE, PHIL J JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:PHIL
Middle Name:J
Last Name:DAIGLE
Suffix:JR
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 1:1017 CECILIA BRIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-6801
Mailing Address - Country:US
Mailing Address - Phone:337-667-6271
Mailing Address - Fax:337-667-7379
Practice Address - Street 1:1017 CECILIA BRIDGE HWY
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-6801
Practice Address - Country:US
Practice Address - Phone:985-513-8459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1898309Other1898309
LA1898309Medicaid