Provider Demographics
NPI:1750696639
Name:BROUSSARD, JOHN EDWARD (RPH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CITIES SERVICE HWY
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5419
Mailing Address - Country:US
Mailing Address - Phone:337-533-1137
Mailing Address - Fax:337-533-9879
Practice Address - Street 1:105 CITIES SERVICE HWY
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5419
Practice Address - Country:US
Practice Address - Phone:337-533-1137
Practice Address - Fax:337-533-9879
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
LA13303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1896195Medicaid
LA09-331OtherLOUISANA BOARD OF PHARMACY MEDICATION ADMINISTRATIONJ REGISTRY NUMBER