Provider Demographics
NPI:1104131200
Name:POWELL, JEREMY (RPH)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:POWELL
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 1:5101 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-3525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5101 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-3525
Practice Address - Country:US
Practice Address - Phone:318-769-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16108183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist