Provider Demographics
NPI:1114000296
Name:PF SPAM LLC
Entity Type:Organization
Organization Name:PF SPAM LLC
Other - Org Name:PAULS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GAGNEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-878-4401
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443-0850
Mailing Address - Country:US
Mailing Address - Phone:985-878-4401
Mailing Address - Fax:985-878-3657
Practice Address - Street 1:345 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2292
Practice Address - Country:US
Practice Address - Phone:985-878-4401
Practice Address - Fax:985-878-3657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
LAPHY.000204-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2030880OtherPK
LA1233161Medicaid
8662389650Medicare NSC