Provider Demographics
NPI:1043688658
Name:FRED'S PHARMACY #3958
Entity Type:Organization
Organization Name:FRED'S PHARMACY #3958
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-559-2433
Mailing Address - Street 1:303 N HOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-2141
Mailing Address - Country:US
Mailing Address - Phone:318-559-2433
Mailing Address - Fax:318-559-2437
Practice Address - Street 1:303 N HOOD ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-2141
Practice Address - Country:US
Practice Address - Phone:318-559-2433
Practice Address - Fax:318-559-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.018472183500000X
MSE-010467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty