Provider Demographics
NPI:1972818698
Name:BROUILLETTE, MANDY (PHARM D)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-4351
Mailing Address - Country:US
Mailing Address - Phone:318-792-7455
Mailing Address - Fax:
Practice Address - Street 1:100 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-5441
Practice Address - Country:US
Practice Address - Phone:318-473-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist