Basic Information
| Provider Information | |||||||||
| NPI: | 1225512767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOUISIANA STATE UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 NORTH STADIUM DRIVE | ||||||||
| Address2: | BROUSSARD CENTER FOR ATHLETIC TRAINING | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255780681 | ||||||||
| FaxNumber: | 2255783924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 NORTH STADIUM DRIVE | ||||||||
| Address2: | BROUSSARD CENTER FOR ATHLETIC TRAINING | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255780681 | ||||||||
| FaxNumber: | 2255783924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | TONI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST-IN-CHARGE | ||||||||
| AuthorizedOfficialTelephone: | 2254853444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOUISIANA STATE UNIVERSITY | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.