Provider Demographics
NPI:1144537028
Name:BAHAM, ANDREA DANIEL (RPH)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DANIEL
Last Name:BAHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10828 PINEBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4057
Mailing Address - Country:US
Mailing Address - Phone:225-295-3551
Mailing Address - Fax:
Practice Address - Street 1:9960 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-6457
Practice Address - Country:US
Practice Address - Phone:225-768-1941
Practice Address - Fax:225-768-7937
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist