Provider Demographics
NPI:1992530331
Name:NUGENT, MATTHEW WADE JR (PHARM D)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WADE
Last Name:NUGENT
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SANBURN RD
Mailing Address - Street 2:
Mailing Address - City:POLLOCK
Mailing Address - State:LA
Mailing Address - Zip Code:71467-3636
Mailing Address - Country:US
Mailing Address - Phone:318-201-8084
Mailing Address - Fax:
Practice Address - Street 1:2951 COTTINGHAM EXPY STE B
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4389
Practice Address - Country:US
Practice Address - Phone:318-640-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.025489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist