1578642401 NPI number — ESTHER WANDA INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578642401 NPI number — ESTHER WANDA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESTHER WANDA 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:
KENNER 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:
1578642401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3108 LOYOLA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNER
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70065-4139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-464-4421
Provider Business Mailing Address Fax Number:
504-469-5995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3108 LOYOLA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNER
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70065-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-464-4421
Provider Business Practice Location Address Fax Number:
504-469-5995
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WANDA
Authorized Official First Name:
ESTHER
Authorized Official Middle Name:
CLARISSE
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
504-464-4421

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5319 , 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: 1271713 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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