Provider Demographics
NPI:1245545482
Name:BRASSEAUX, SHANNON (RPH)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:
Last Name:BRASSEAUX
Suffix:
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 1:14639 AIRLINE HWY STE 114
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-6632
Mailing Address - Country:US
Mailing Address - Phone:254-070-4442
Mailing Address - Fax:225-402-4088
Practice Address - Street 1:14639 AIRLINE HWY STE 114
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-6632
Practice Address - Country:US
Practice Address - Phone:225-070-4444
Practice Address - Fax:225-402-4088
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist