Provider Demographics
NPI:1740510684
Name:BELANGER, KIM THIBODEAUX (PD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:THIBODEAUX
Last Name:BELANGER
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:ELIZABETH
Other - Last Name:THIBODEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 LYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-6224
Mailing Address - Country:US
Mailing Address - Phone:985-851-1639
Mailing Address - Fax:
Practice Address - Street 1:106 LYNWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-6224
Practice Address - Country:US
Practice Address - Phone:985-851-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-26
Last Update Date:2009-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11851OtherPHARMACIST LICENSE