Provider Demographics
NPI:1043838469
Name:VIDRINE PHARMACEUTICAL GROUP, LLC
Entity Type:Organization
Organization Name:VIDRINE PHARMACEUTICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDRINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-436-7216
Mailing Address - Street 1:404 E PRIEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8507
Mailing Address - Country:US
Mailing Address - Phone:337-436-7216
Mailing Address - Fax:
Practice Address - Street 1:404 E PRIEN LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8507
Practice Address - Country:US
Practice Address - Phone:337-436-7216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIDRINE PHARMACEUTICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-13
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy