Provider Demographics
NPI:1124125679
Name:PAINCOURTVILLE PHARMACY INC.
Entity type:Organization
Organization Name:PAINCOURTVILLE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGONA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:985-369-3578
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:PAINCOURTVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70391-0420
Mailing Address - Country:US
Mailing Address - Phone:985-369-3578
Mailing Address - Fax:395-369-3579
Practice Address - Street 1:112 HWY 403
Practice Address - Street 2:
Practice Address - City:PAINCOURTVILLE
Practice Address - State:LA
Practice Address - Zip Code:70391
Practice Address - Country:US
Practice Address - Phone:985-369-3578
Practice Address - Fax:985-369-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1915202OtherNCPDP
LA1234125Medicaid