Provider Demographics
NPI:1124109764
Name:HENDERSON, EARL D
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:ZWOLLE
Mailing Address - State:LA
Mailing Address - Zip Code:71486-0608
Mailing Address - Country:US
Mailing Address - Phone:318-645-4640
Mailing Address - Fax:318-645-2209
Practice Address - Street 1:1169 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ZWOLLE
Practice Address - State:LA
Practice Address - Zip Code:71486-0608
Practice Address - Country:US
Practice Address - Phone:318-645-4640
Practice Address - Fax:318-645-2209
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1250945Medicaid
LA1080340001Medicare NSC