Provider Demographics
NPI:1194129775
Name:THIBODEAUX, DWIGHT PAUL (RPH)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:PAUL
Last Name:THIBODEAUX
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 1:36189 NORFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-8587
Mailing Address - Country:US
Mailing Address - Phone:225-924-1930
Mailing Address - Fax:225-924-2620
Practice Address - Street 1:5551 CORPORATE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-2567
Practice Address - Country:US
Practice Address - Phone:225-924-1930
Practice Address - Fax:225-924-2620
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.016695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist