1457348641 NPI number — ACADIANA PHARMACEUTICAL MEDICAL LLC

Table of content: (NPI 1457348641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457348641 NPI number — ACADIANA PHARMACEUTICAL MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACADIANA PHARMACEUTICAL MEDICAL 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:
LIFEHOUSE MEDICAL
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:
1457348641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22203 A HWY 59
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROBERTSDALE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-945-1540
Provider Business Mailing Address Fax Number:
251-945-1542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22203 A HWY 59
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROBERTSDALE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-945-1540
Provider Business Practice Location Address Fax Number:
251-945-1542
Provider Enumeration Date:
10/03/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
REYBURN
Authorized Official Title or Position:
DIRECTOR OF PHARMACY LLC MEMBER
Authorized Official Telephone Number:
251-945-1540

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 333600000X , with the licence number: 112604 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 0132833 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".