Basic Information
Provider Information
NPI: 1003004078
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILLIS
FirstName: RALPH
MiddleName: F
NamePrefix:  
NameSuffix:  
Credential: PD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1852 BUSHVILLE HWY
Address2:  
City: ARNAUDVILLE
State: LA
PostalCode: 705124106
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1852 BUSHVILLE HWY
Address2:  
City: ARNAUDVILLE
State: LA
PostalCode: 705124106
CountryCode: US
TelephoneNumber: 3377545933
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/04/2007
LastUpdateDate: 10/04/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X8660LAY Pharmacy Service ProvidersPharmacist 

No ID Information.


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