Provider Demographics
NPI:1316688781
Name:JOUBERT, CORNELL M
Entity type:Individual
Prefix:
First Name:CORNELL
Middle Name:M
Last Name:JOUBERT
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 1:2708 RUE CANNES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4044
Mailing Address - Country:US
Mailing Address - Phone:337-426-2899
Mailing Address - Fax:
Practice Address - Street 1:2708 RUE CANNES DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4044
Practice Address - Country:US
Practice Address - Phone:337-426-2899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist