Provider Demographics
NPI:1265731848
Name:BOUTTE, KENNETH GERARD JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GERARD
Last Name:BOUTTE
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 I 10 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70128-2248
Mailing Address - Country:US
Mailing Address - Phone:504-458-9311
Mailing Address - Fax:
Practice Address - Street 1:416 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5544
Practice Address - Country:US
Practice Address - Phone:601-798-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-010671183500000X
TX48331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist