Provider Demographics
NPI:1871102939
Name:DANIEL, PATRICIA WADE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:WADE
Last Name:DANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 DUMMY LINE RD
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-7767
Mailing Address - Country:US
Mailing Address - Phone:318-376-2136
Mailing Address - Fax:
Practice Address - Street 1:2907 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5337
Practice Address - Country:US
Practice Address - Phone:318-325-3142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist