Provider Demographics
NPI:1104144245
Name:FANGUY, BRAD JOSEPH (PHARMD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:JOSEPH
Last Name:FANGUY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BENTWATER DR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518
Mailing Address - Country:US
Mailing Address - Phone:985-860-2565
Mailing Address - Fax:
Practice Address - Street 1:106 ABIGAYLE ROW
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:LA
Practice Address - Zip Code:70583-8909
Practice Address - Country:US
Practice Address - Phone:337-268-4023
Practice Address - Fax:337-268-4043
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1899453Medicaid