Provider Demographics
NPI:1962589549
Name:HEALTH MART OF LAFAYETTE LLC
Entity type:Organization
Organization Name:HEALTH MART OF LAFAYETTE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-235-3523
Mailing Address - Street 1:818 N CUSHING AVE
Mailing Address - Street 2:
Mailing Address - City:KAPLAN
Mailing Address - State:LA
Mailing Address - Zip Code:70548-2615
Mailing Address - Country:US
Mailing Address - Phone:337-235-3523
Mailing Address - Fax:337-233-1518
Practice Address - Street 1:600 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-8060
Practice Address - Country:US
Practice Address - Phone:337-235-3523
Practice Address - Fax:337-233-1518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X, 3336S0011X
LAPHY006433IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132567OtherPK
LA2201000Medicaid
2132567OtherPK