Provider Demographics
NPI:1255730156
Name:MOUTON, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOUTON
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 1:3005 CHARITY ST
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70510-4140
Mailing Address - Country:US
Mailing Address - Phone:337-893-4077
Mailing Address - Fax:337-893-4079
Practice Address - Street 1:3005 CHARITY ST
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-4140
Practice Address - Country:US
Practice Address - Phone:337-893-4077
Practice Address - Fax:337-893-4079
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist