Provider Demographics
NPI:1053868919
Name:FITCH, DOMINIQUE (PHARMD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:FITCH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 VAN CLEAVE DR
Mailing Address - Street 2:
Mailing Address - City:MERAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70075-8024
Mailing Address - Country:US
Mailing Address - Phone:504-909-3025
Mailing Address - Fax:
Practice Address - Street 1:2601 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5167
Practice Address - Country:US
Practice Address - Phone:228-497-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE14646183500000X
LAPST. 021620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist