1992245468 NPI number — THRIFTY WAY PHARMACY OF MAMOU LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992245468 NPI number — THRIFTY WAY PHARMACY OF MAMOU LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIFTY WAY PHARMACY OF MAMOU LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992245468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
704 POINCIANA AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MAMOU
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70554-2224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-468-7111
Provider Business Mailing Address Fax Number:
337-468-2111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
704 POINCIANA AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MAMOU
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70554-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-468-7111
Provider Business Practice Location Address Fax Number:
337-468-2111
Provider Enumeration Date:
03/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
JAIN
Authorized Official First Name:
AMIT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
713-660-8888

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHY007406IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY007406IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1254304 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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