Provider Demographics
NPI:1386418937
Name:THE WIG RX LLC
Entity type:Organization
Organization Name:THE WIG RX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATAJA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-840-9447
Mailing Address - Street 1:3309 WILLIAMSBURG PL
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112
Mailing Address - Country:US
Mailing Address - Phone:318-840-9447
Mailing Address - Fax:
Practice Address - Street 1:3309 WILLIAMSBURG PL
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112
Practice Address - Country:US
Practice Address - Phone:318-840-9447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier