Provider Demographics
NPI:1902969520
Name:JAMES DRUG STORE LLC
Entity type:Organization
Organization Name:JAMES DRUG STORE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC AND VP
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:225-665-5186
Mailing Address - Street 1:257 FLORIDA AVE SE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-3798
Mailing Address - Country:US
Mailing Address - Phone:225-665-5186
Mailing Address - Fax:225-667-0306
Practice Address - Street 1:257 FLORIDA AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-3728
Practice Address - Country:US
Practice Address - Phone:225-665-5186
Practice Address - Fax:225-665-8633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2972IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1262595Medicaid
2028652OtherPK
LA1262595Medicaid