Provider Demographics
NPI:1841599586
Name:INGALLS, PAUL WALLACE (PHARMD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:WALLACE
Last Name:INGALLS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16445 N ANTIOCH XING
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-4879
Mailing Address - Country:US
Mailing Address - Phone:225-636-2480
Mailing Address - Fax:
Practice Address - Street 1:4848 ONEAL LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1639
Practice Address - Country:US
Practice Address - Phone:225-753-9662
Practice Address - Fax:225-752-5856
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.017930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist