Provider Demographics
NPI:1669755302
Name:PROVOST, MICHAEL M (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:PROVOST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 OLE HIGHWAY 15 LOT 92
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-1413
Mailing Address - Country:US
Mailing Address - Phone:318-680-3590
Mailing Address - Fax:
Practice Address - Street 1:755 OLE HIGHWAY 15 LOT 92
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-1413
Practice Address - Country:US
Practice Address - Phone:318-680-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist