Provider Demographics
NPI:1700509049
Name:MIZELL, SYDNEY WADE
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:WADE
Last Name:MIZELL
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 1:821 TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-2943
Mailing Address - Country:US
Mailing Address - Phone:985-750-9975
Mailing Address - Fax:
Practice Address - Street 1:731 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FRANKLINTON
Practice Address - State:LA
Practice Address - Zip Code:70438-6900
Practice Address - Country:US
Practice Address - Phone:985-839-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.024521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist