Provider Demographics
NPI:1053712760
Name:CHAMPAGNE, SIDNEY (RPH)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:
Last Name:CHAMPAGNE
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 1:900 E ADMIRAL DOYLE DR
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-6709
Mailing Address - Country:US
Mailing Address - Phone:337-367-2291
Mailing Address - Fax:337-365-0162
Practice Address - Street 1:106 CANDLEGLOW DR
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-0912
Practice Address - Country:US
Practice Address - Phone:337-560-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist