Provider Demographics
NPI:1285130385
Name:METAIRIE HEALTH MART LLC
Entity type:Organization
Organization Name:METAIRIE HEALTH MART LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-316-3036
Mailing Address - Street 1:PO BOX 1907
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70004-1907
Mailing Address - Country:US
Mailing Address - Phone:504-264-7206
Mailing Address - Fax:504-264-7831
Practice Address - Street 1:3735 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5836
Practice Address - Country:US
Practice Address - Phone:504-264-7206
Practice Address - Fax:504-264-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-05
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.007675-IR3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176957OtherPK
LAPENDINGMedicaid