Provider Demographics
NPI:1194144394
Name:MODI, ASHISH G (PHARMD)
Entity type:Individual
Prefix:
First Name:ASHISH
Middle Name:G
Last Name:MODI
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 1:6235 WESTPORT AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2503
Mailing Address - Country:US
Mailing Address - Phone:318-688-7911
Mailing Address - Fax:318-688-7911
Practice Address - Street 1:6235 WESTPORT AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2503
Practice Address - Country:US
Practice Address - Phone:318-688-7911
Practice Address - Fax:318-688-7911
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist