Provider Demographics
NPI:1487747101
Name:FAMILY DRUG MART, LLC
Entity type:Organization
Organization Name:FAMILY DRUG MART, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:YANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:985-641-7557
Mailing Address - Street 1:2299 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5605
Mailing Address - Country:US
Mailing Address - Phone:985-641-7557
Mailing Address - Fax:833-909-2104
Practice Address - Street 1:140 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-641-7557
Practice Address - Fax:833-909-2104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1234168Medicaid