Provider Demographics
NPI:1073518643
Name:MEDSOURCE PHARMACY SERVICES
Entity Type:Organization
Organization Name:MEDSOURCE PHARMACY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-487-1884
Mailing Address - Street 1:2223 WORLEY DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2223 WORLEY DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3631
Practice Address - Country:US
Practice Address - Phone:318-487-1884
Practice Address - Fax:318-487-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14961333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1270750Medicaid
1931016OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1931016OtherOTHER ID NUMBER-COMMERCIAL NUMBER