Provider Demographics
NPI:1104412154
Name:JEFFERSON DRUG PHARMACY
Entity type:Organization
Organization Name:JEFFERSON DRUG PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AIGBFOH
Authorized Official - Suffix:I
Authorized Official - Credentials:PHARMD,
Authorized Official - Phone:443-540-4597
Mailing Address - Street 1:616 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-7206
Mailing Address - Country:US
Mailing Address - Phone:337-889-3795
Mailing Address - Fax:337-889-3796
Practice Address - Street 1:616 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7206
Practice Address - Country:US
Practice Address - Phone:337-889-3795
Practice Address - Fax:337-889-3796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-14
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2208241Medicaid