Provider Demographics
NPI:1669754800
Name:BONNEAU, KENNETH JOSEPH
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:BONNEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3754 MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-5537
Mailing Address - Country:US
Mailing Address - Phone:337-269-9300
Mailing Address - Fax:337-235-7416
Practice Address - Street 1:3754 MOSS ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70507-5537
Practice Address - Country:US
Practice Address - Phone:337-269-9300
Practice Address - Fax:337-235-7416
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist