1447500590 NPI number — RED RIVER PHARMACY LONG TERM CARE, LLC

Table of content: (NPI 1447500590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447500590 NPI number — RED RIVER PHARMACY LONG TERM CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED RIVER PHARMACY LONG TERM CARE, 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:
1447500590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1550 MOORES LN STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-4657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-617-6885
Provider Business Mailing Address Fax Number:
903-617-6972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 TROUP HWY
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-2356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-617-6885
Provider Business Practice Location Address Fax Number:
844-308-8629
Provider Enumeration Date:
09/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOUDREAUX
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
903-792-1721

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  28138 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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