Provider Demographics
NPI:1902202328
Name:HUTSON, JANICE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:HUTSON
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 1:113 PARKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-2196
Mailing Address - Country:US
Mailing Address - Phone:318-348-1263
Mailing Address - Fax:318-966-6294
Practice Address - Street 1:2600 TOWER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5766
Practice Address - Country:US
Practice Address - Phone:318-966-6290
Practice Address - Fax:318-966-6294
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1804495Medicaid