Provider Demographics
NPI:1891079299
Name:HUBER, WILLIAM WALLACE
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:WALLACE
Last Name:HUBER
Suffix:
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 1:2311 SHADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2845
Mailing Address - Country:US
Mailing Address - Phone:225-756-7090
Mailing Address - Fax:
Practice Address - Street 1:5360 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-6548
Practice Address - Country:US
Practice Address - Phone:225-757-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010556183500000X
AZ015740183500000X
AL16229183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist