Provider Demographics
NPI:1386460004
Name:BROUSSARD, RICHARD WAYNE
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
Last Name:BROUSSARD
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 1:403 E HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TX
Mailing Address - Zip Code:77535-2629
Mailing Address - Country:US
Mailing Address - Phone:936-258-2166
Mailing Address - Fax:936-258-2166
Practice Address - Street 1:403 E HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2629
Practice Address - Country:US
Practice Address - Phone:936-258-2166
Practice Address - Fax:936-258-7617
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist