Provider Demographics
NPI:1265930457
Name:OSEBRE, MARK KWAME (PHARMACIST)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KWAME
Last Name:OSEBRE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 WALTERS ST APT 21
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4643
Mailing Address - Country:US
Mailing Address - Phone:973-738-6762
Mailing Address - Fax:
Practice Address - Street 1:120 US-171
Practice Address - Street 2:
Practice Address - City:MOSS BLUFF
Practice Address - State:LA
Practice Address - Zip Code:70611
Practice Address - Country:US
Practice Address - Phone:337-855-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA048347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA048347OtherLOUISIAN BOARD OF PHARMACY