Provider Demographics
NPI:1962968404
Name:COASTAL PHARMACY SERVICES LLC
Entity type:Organization
Organization Name:COASTAL PHARMACY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:985-792-9001
Mailing Address - Street 1:1922 HIGHWAY 22 W STE A
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9490
Mailing Address - Country:US
Mailing Address - Phone:985-792-9001
Mailing Address - Fax:985-792-9004
Practice Address - Street 1:190 GREENBRIER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7237
Practice Address - Country:US
Practice Address - Phone:985-900-2416
Practice Address - Fax:985-900-2436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL PHARMACY SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-20
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2206672Medicaid