Provider Demographics
NPI:1023484920
Name:BROUSSARD, LATRISHA (PHARM D)
Entity type:Individual
Prefix:DR
First Name:LATRISHA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
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 1:105 TULIP WOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2477
Mailing Address - Country:US
Mailing Address - Phone:318-387-6023
Mailing Address - Fax:319-387-6367
Practice Address - Street 1:2801 LOUISVILLE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6655
Practice Address - Country:US
Practice Address - Phone:318-387-6023
Practice Address - Fax:318-387-6367
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist