Individual
DEREK FONTENOT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2011 RYAN ST, LAKE CHARLES, LA 70601-7313
(337) 508-3864
Mailing address
1531 COUNTRY CLUB RD APT 511, LAKE CHARLES, LA 70605-5343
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
PST.021842
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PST.021842
LOUISIANA BOARD OF PHARMACY
LA
Enumeration date
12/21/2016
Last updated
12/21/2016
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