Provider Demographics
NPI:1114041134
Name:PEARSON DRUGS NO. 4, LLC
Entity Type:Organization
Organization Name:PEARSON DRUGS NO. 4, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-445-1488
Mailing Address - Street 1:PO BOX 3640
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71361-3640
Mailing Address - Country:US
Mailing Address - Phone:318-619-1129
Mailing Address - Fax:318-473-2879
Practice Address - Street 1:900 N 5TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-3544
Practice Address - Country:US
Practice Address - Phone:337-239-4521
Practice Address - Fax:337-238-4957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA870RC3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1217328Medicaid
LA1920239OtherNCPDP NO.
LA1217328Medicaid