Provider Demographics
NPI:1245885698
Name:LANDRY, JONATHAN MATTHEW
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:LANDRY
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 1:103 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4616
Mailing Address - Country:US
Mailing Address - Phone:337-839-8880
Mailing Address - Fax:337-839-8881
Practice Address - Street 1:103 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-4616
Practice Address - Country:US
Practice Address - Phone:337-839-8880
Practice Address - Fax:337-839-8881
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.023104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist