Provider Demographics
NPI: | 1124183256 |
---|---|
Name: | FOLSOM PHARMACY, INC |
Entity Type: | Organization |
Organization Name: | FOLSOM PHARMACY, INC |
Other - Org Name: | FOLSOM FAMILY PHARMACY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER/PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KATHRYN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BERNIER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 985-796-3062 |
Mailing Address - Street 1: | 305 SAINT PAUL ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MADISONVILLE |
Mailing Address - State: | LA |
Mailing Address - Zip Code: | 70447-9328 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 82150 HWY 25 |
Practice Address - Street 2: | |
Practice Address - City: | FOLSOM |
Practice Address - State: | LA |
Practice Address - Zip Code: | 70437 |
Practice Address - Country: | US |
Practice Address - Phone: | 985-796-3062 |
Practice Address - Fax: | 985-796-9977 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-12-27 |
Last Update Date: | 2019-09-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
LA | 2204831 | Medicaid | |
LA | 2201816 | Medicaid |