Provider Demographics
NPI:1932508660
Name:MCCULLOUGH, MONETTE MARIA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MONETTE
Middle Name:MARIA
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70818-4305
Mailing Address - Country:US
Mailing Address - Phone:225-262-1413
Mailing Address - Fax:225-262-5513
Practice Address - Street 1:10200 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70818-4305
Practice Address - Country:US
Practice Address - Phone:225-262-1413
Practice Address - Fax:225-262-5513
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist