1407282585 NPI number — FOUNTAIN PARK PHARMACY INC.

Table of content: (NPI 1407282585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407282585 NPI number — FOUNTAIN PARK PHARMACY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN PARK PHARMACY 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:
FOUNTAIN PARK PHARMACY INC.
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:
1407282585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 MANHATTAN BLVD
Provider Second Line Business Mailing Address:
BUILDING F SUITE 104
Provider Business Mailing Address City Name:
HARVEY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70058-3582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-434-4777
Provider Business Mailing Address Fax Number:
504-309-8031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 MANHATTAN BLVD
Provider Second Line Business Practice Location Address:
BUILDING F SUITE 104
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70058-3582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-434-4777
Provider Business Practice Location Address Fax Number:
504-309-8031
Provider Enumeration Date:
09/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
CULOTTA
Authorized Official First Name:
JO STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
504-434-4777

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY007141IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: LA1845 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 114250 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 333600000X , with the licence number: 5277 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 14022/7.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 15677 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 22-44626 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PH27207 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: PHNR000702 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2142276 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2204238 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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