Provider Demographics
NPI:1487783171
Name:MAYLON, JEANNE BOURQUE
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:BOURQUE
Last Name:MAYLON
Suffix:
Gender:F
Credentials:
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 1511
Mailing Address - Street 2:
Mailing Address - City:GRAMERCY
Mailing Address - State:LA
Mailing Address - Zip Code:70052-1511
Mailing Address - Country:US
Mailing Address - Phone:225-869-3651
Mailing Address - Fax:225-869-8826
Practice Address - Street 1:1635 HIGHWAY 3125
Practice Address - Street 2:
Practice Address - City:GRAMERCY
Practice Address - State:LA
Practice Address - Zip Code:70052
Practice Address - Country:US
Practice Address - Phone:225-869-3651
Practice Address - Fax:225-869-8826
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist