Provider Demographics
NPI:1689408882
Name:TSAFACK, THEOPHILE
Entity type:Individual
Prefix:
First Name:THEOPHILE
Middle Name:
Last Name:TSAFACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 BON AIRE DR APT 121
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-3073
Mailing Address - Country:US
Mailing Address - Phone:318-237-9142
Mailing Address - Fax:
Practice Address - Street 1:5350 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7506
Practice Address - Country:US
Practice Address - Phone:318-396-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.025449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist