Provider Demographics
NPI:1174516272
Name:DISHMAN, JAYNE WALLACE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JAYNE
Middle Name:WALLACE
Last Name:DISHMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 OAK MANOR DR
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-2223
Mailing Address - Country:US
Mailing Address - Phone:337-369-9783
Mailing Address - Fax:337-365-0563
Practice Address - Street 1:308 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2843
Practice Address - Country:US
Practice Address - Phone:337-364-7671
Practice Address - Fax:337-365-0563
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15565183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist