Provider Demographics
NPI:1003033101
Name:CLIFTON G. ELLIOTT, LLC
Entity Type:Organization
Organization Name:CLIFTON G. ELLIOTT, LLC
Other - Org Name:ELLIOTT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-625-2353
Mailing Address - Street 1:PO BOX 86
Mailing Address - Street 2:
Mailing Address - City:MARINGOUIN
Mailing Address - State:LA
Mailing Address - Zip Code:70757-0086
Mailing Address - Country:US
Mailing Address - Phone:225-625-2353
Mailing Address - Fax:225-625-3144
Practice Address - Street 1:77395 LANDRY DR
Practice Address - Street 2:
Practice Address - City:MARINGOUIN
Practice Address - State:LA
Practice Address - Zip Code:70757-3208
Practice Address - Country:US
Practice Address - Phone:225-625-2353
Practice Address - Fax:225-625-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
LA4742IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1270806Medicaid
2028923OtherPK
2028923OtherPK