Provider Demographics
NPI:1750696621
Name:SIMMONS, MICHAEL THOMAS (PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:SIMMONS
Suffix:
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 1:13500 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:BOUTTE
Mailing Address - State:LA
Mailing Address - Zip Code:70039-3500
Mailing Address - Country:US
Mailing Address - Phone:985-331-1866
Mailing Address - Fax:985-331-8256
Practice Address - Street 1:13500 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:BOUTTE
Practice Address - State:LA
Practice Address - Zip Code:70039-3500
Practice Address - Country:US
Practice Address - Phone:985-331-1866
Practice Address - Fax:985-331-8256
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1233706Medicaid