1205243730 NPI number — FAMILY PHARMACY LLC

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 1205243730 NPI number — FAMILY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY 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:
Provider Other Organization Name Type Code:
6
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:
1205243730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1812 W THOMAS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMMOND
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70401-2945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-345-4767
Provider Business Mailing Address Fax Number:
985-345-4768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34876 LA HIGHWAY 1019
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENHAM SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70706-0659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-667-4286
Provider Business Practice Location Address Fax Number:
225-664-1682
Provider Enumeration Date:
07/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TINNERELLO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
985-320-5175

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.006946-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: 2149065 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2203177 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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