Provider Demographics
NPI:1336577576
Name:SCARDULLA, PENNY
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:SCARDULLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 AVE. G
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:70444
Mailing Address - Country:US
Mailing Address - Phone:985-229-6210
Mailing Address - Fax:985-229-3131
Practice Address - Street 1:717 AVE. G
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:LA
Practice Address - Zip Code:70444
Practice Address - Country:US
Practice Address - Phone:985-229-6210
Practice Address - Fax:985-229-3131
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14234183500000X
MS12839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist