Provider Demographics
NPI:1073625927
Name:ICARE PHARMACY - JOHNSTON STREET LLC
Entity Type:Organization
Organization Name:ICARE PHARMACY - JOHNSTON STREET LLC
Other - Org Name:ICARE PHARMACY - JOHNSTON ST, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLEVELAND
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-4782
Mailing Address - Street 1:2039 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2784
Mailing Address - Country:US
Mailing Address - Phone:337-233-4782
Mailing Address - Fax:337-233-4783
Practice Address - Street 1:2039 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2784
Practice Address - Country:US
Practice Address - Phone:337-233-4782
Practice Address - Fax:337-233-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
LAPHY006927IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2202972Medicaid
2147225OtherPK
LA1094790001Medicare NSC