1659417202 NPI number — CANNONS DISCOUNT PHARMACY LLC

Table of content: (NPI 1659417202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659417202 NPI number — CANNONS DISCOUNT PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANNONS DISCOUNT PHARMACY LLC
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:
CANNONS DISCOUNT 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:
1659417202
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
182 W 3RD ST
Provider Second Line Business Mailing Address:
BLDG. A
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70062-7056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-667-4433
Provider Business Mailing Address Fax Number:
504-539-3716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13351 E ALESSI RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70443-2398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-878-5555
Provider Business Practice Location Address Fax Number:
985-878-5553
Provider Enumeration Date:
01/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
MANG
Authorized Official Telephone Number:
504-415-7595

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY.005972-IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1268798 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2035430 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1227901 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".