Provider Demographics
NPI:1962834630
Name:BORDELON, CARLY KRISTIN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:CARLY
Middle Name:KRISTIN
Last Name:BORDELON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18083 THREE RIVERS RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8950
Mailing Address - Country:US
Mailing Address - Phone:504-419-7487
Mailing Address - Fax:
Practice Address - Street 1:1619 S COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-5824
Practice Address - Country:US
Practice Address - Phone:985-732-5752
Practice Address - Fax:985-732-5921
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST020209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist