Provider Demographics
NPI:1306901434
Name:DE BLANC DRUG STORE
Entity type:Organization
Organization Name:DE BLANC DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:COUSINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:504-949-8346
Mailing Address - Street 1:3111 GRAND RTE ST JOHN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119
Mailing Address - Country:US
Mailing Address - Phone:504-949-8346
Mailing Address - Fax:504-949-5146
Practice Address - Street 1:3111 GRAND RTE ST JOHN ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119
Practice Address - Country:US
Practice Address - Phone:504-949-8346
Practice Address - Fax:504-949-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
LA1618IR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1212245Medicaid
1908702OtherOTHER ID NUMBER-COMMERCIAL NUMBER