Provider Demographics
NPI:1114079464
Name:ROUSES DISCOUNT PHCY
Entity Type:Organization
Organization Name:ROUSES DISCOUNT PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-447-5998
Mailing Address - Street 1:PO BOX 5358
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1175 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4940
Practice Address - Country:US
Practice Address - Phone:985-446-3011
Practice Address - Fax:985-446-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3270333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1263095Medicaid
1926560OtherOTHER ID NUMBER-COMMERCIAL NUMBER