Provider Demographics
NPI:1285115428
Name:PERRODIN, KEVIN TROY JR
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:TROY
Last Name:PERRODIN
Suffix:JR
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 1:1716 RYAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-0970
Mailing Address - Country:US
Mailing Address - Phone:337-256-1500
Mailing Address - Fax:
Practice Address - Street 1:1017 E ADMIRAL DOYLE DR
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-6710
Practice Address - Country:US
Practice Address - Phone:337-367-7979
Practice Address - Fax:337-367-9122
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.022652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist