Provider Demographics
NPI:1003827510
Name:THRIFTY WAY PHARMACY OF DERIDDER INC NO 2
Entity Type:Organization
Organization Name:THRIFTY WAY PHARMACY OF DERIDDER INC NO 2
Other - Org Name:THRIFTY WAY PHARMACY #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-430-3784
Mailing Address - Street 1:601 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-4941
Mailing Address - Country:US
Mailing Address - Phone:337-463-7442
Mailing Address - Fax:337-462-0362
Practice Address - Street 1:601 S PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4941
Practice Address - Country:US
Practice Address - Phone:337-463-7442
Practice Address - Fax:337-462-0362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY001316IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1216917Medicaid
2030865OtherPK
1092230001Medicare NSC