Provider Demographics
NPI:1992104731
Name:BOURQUE, JAKE A (PHARMD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:A
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535-5300
Mailing Address - Country:US
Mailing Address - Phone:337-546-6386
Mailing Address - Fax:
Practice Address - Street 1:621 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-5300
Practice Address - Country:US
Practice Address - Phone:337-546-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.020714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist