Provider Demographics
NPI:1093223323
Name:THRIFT-TOWN HEALTHMART, LLC
Entity Type:Organization
Organization Name:THRIFT-TOWN HEALTHMART, LLC
Other - Org Name:THRIFT-TOWN HEALTHMART PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EVANS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:GLASGOW
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:985-748-8191
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-0918
Mailing Address - Country:US
Mailing Address - Phone:985-748-8191
Mailing Address - Fax:985-748-5766
Practice Address - Street 1:512 N 2ND ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2123
Practice Address - Country:US
Practice Address - Phone:985-748-8191
Practice Address - Fax:985-748-5766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
LA61643336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1235245Medicaid
2175570OtherPK