Provider Demographics
NPI:1871875450
Name:LEGAUX, BRENDA THOMAS
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:THOMAS
Last Name:LEGAUX
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 1:3124 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4240
Mailing Address - Country:US
Mailing Address - Phone:318-222-4807
Mailing Address - Fax:318-222-6995
Practice Address - Street 1:3124 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4240
Practice Address - Country:US
Practice Address - Phone:318-222-4807
Practice Address - Fax:318-222-6995
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15289183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist