Provider Demographics
NPI:1912326968
Name:ICARE JOHNSTON STREET
Entity type:Organization
Organization Name:ICARE JOHNSTON STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:TERESA W
Authorized Official - Last Name:ANDREPONT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-4782
Mailing Address - Street 1:2039 JOHNSTON STREET
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-233-4782
Mailing Address - Fax:337-233-4783
Practice Address - Street 1:2039 JOHNSTON STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-233-4782
Practice Address - Fax:337-233-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy