1447354402 NPI number — INCA ENTERPRISES INC

Table of content: (NPI 1447354402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447354402 NPI number — INCA ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INCA ENTERPRISES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDICS COMPOUNDING PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447354402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6119
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71136-6119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-865-0234
Provider Business Mailing Address Fax Number:
318-865-3972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1847 LINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-222-8477
Provider Business Practice Location Address Fax Number:
318-222-8487
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURCH
Authorized Official First Name:
CLOVIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
318-865-0234

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY.003693-IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1266957 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2034911 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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