Provider Demographics
NPI:1306117973
Name:SMOTHERMAN, RICKEY (RPH)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:SMOTHERMAN
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:OLLA
Mailing Address - State:LA
Mailing Address - Zip Code:71465-0699
Mailing Address - Country:US
Mailing Address - Phone:318-495-5155
Mailing Address - Fax:318-495-5635
Practice Address - Street 1:2832 FRONT STREET
Practice Address - Street 2:
Practice Address - City:OLLA
Practice Address - State:LA
Practice Address - Zip Code:71465
Practice Address - Country:US
Practice Address - Phone:318-495-5155
Practice Address - Fax:318-495-5635
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1254045Medicaid