Provider Demographics
NPI:1063554574
Name:DARTEZ, RYAN M (RPH, MBA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:DARTEZ
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 MILL POND DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5655
Mailing Address - Country:US
Mailing Address - Phone:337-278-3007
Mailing Address - Fax:337-235-4570
Practice Address - Street 1:509 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6905
Practice Address - Country:US
Practice Address - Phone:337-235-4578
Practice Address - Fax:337-235-4570
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1895997Medicaid
LA15874OtherPHARMACIST LICENSE