1679519607 NPI number — DUTCHTOWN PHARMACY L L C

Table of content: (NPI 1679519607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679519607 NPI number — DUTCHTOWN PHARMACY L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUTCHTOWN PHARMACY L L C
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:
1679519607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2014
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:
225-677-5070
Provider Business Mailing Address Fax Number:
225-673-5060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13011 HIGHWAY 73
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEISMAR
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70734-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-677-5070
Provider Business Practice Location Address Fax Number:
225-673-5060
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY-005662-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: 2035369 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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