Provider Demographics
NPI:1427332238
Name:THIBODEAUX, CARL P (PD)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:P
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5889 AIRLINE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805
Mailing Address - Country:US
Mailing Address - Phone:225-357-1407
Mailing Address - Fax:225-357-1865
Practice Address - Street 1:5889 AIRLINE HIGHWAY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805
Practice Address - Country:US
Practice Address - Phone:225-357-1407
Practice Address - Fax:225-357-1865
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist