1508396656 NPI number — BENNIE G. OWENS

Table of content: ALEXIS DUPREE YOUNG MSW (NPI 1063226348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508396656 NPI number — BENNIE G. OWENS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENNIE G. OWENS
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:
1508396656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 68
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANSPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71049-0068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-697-4381
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANSPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71049-2997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-697-4381
Provider Business Practice Location Address Fax Number:
318-697-5311
Provider Enumeration Date:
06/12/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OWENS
Authorized Official First Name:
BENNIE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/PHARMACIST
Authorized Official Telephone Number:
318-697-4381

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  452-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: 580009 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1219754 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1907116 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".