Provider Demographics
NPI:1043527435
Name:MICHAUD, CLEVELAND GLYNN JR
Entity type:Individual
Prefix:MR
First Name:CLEVELAND
Middle Name:GLYNN
Last Name:MICHAUD
Suffix:JR
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 1:1200 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUNICE
Mailing Address - State:LA
Mailing Address - Zip Code:70535-4320
Mailing Address - Country:US
Mailing Address - Phone:337-457-5216
Mailing Address - Fax:337-457-0920
Practice Address - Street 1:1200 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EUNICE
Practice Address - State:LA
Practice Address - Zip Code:70535-4320
Practice Address - Country:US
Practice Address - Phone:337-457-5216
Practice Address - Fax:337-457-0920
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18670183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist