Provider Demographics
NPI:1154941631
Name:LOPEZ, JONATHAN BLAINE
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BLAINE
Last Name:LOPEZ
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 1:1725 W SALE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-2521
Mailing Address - Country:US
Mailing Address - Phone:337-474-7001
Mailing Address - Fax:337-474-7088
Practice Address - Street 1:1725 W SALE RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2521
Practice Address - Country:US
Practice Address - Phone:337-474-7001
Practice Address - Fax:337-474-7088
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA.017781183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist