Provider Demographics
NPI:1992037022
Name:HUCKABY, ANITA GAIL
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:GAIL
Last Name:HUCKABY
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 1:500 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-2002
Mailing Address - Country:US
Mailing Address - Phone:318-259-7334
Mailing Address - Fax:318-259-3013
Practice Address - Street 1:500 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2002
Practice Address - Country:US
Practice Address - Phone:318-259-7334
Practice Address - Fax:318-259-3013
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1810495Medicaid