Provider Demographics
NPI:1841620234
Name:DOMINGUE, EDWIN PAUL JR (PD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:PAUL
Last Name:DOMINGUE
Suffix:JR
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-4756
Mailing Address - Country:US
Mailing Address - Phone:337-988-2711
Mailing Address - Fax:
Practice Address - Street 1:105 DUNCAN DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4756
Practice Address - Country:US
Practice Address - Phone:337-988-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST 10459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist