Provider Demographics
NPI:1124190913
Name:MEDICINE SHOPPE OF GREATER BR INC
Entity Type:Organization
Organization Name:MEDICINE SHOPPE OF GREATER BR INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:225-644-3030
Mailing Address - Street 1:1817 S BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4429
Mailing Address - Country:US
Mailing Address - Phone:224-644-3030
Mailing Address - Fax:225-647-2706
Practice Address - Street 1:1817 S BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4429
Practice Address - Country:US
Practice Address - Phone:225-644-3030
Practice Address - Fax:225-647-2706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LA2414IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1259659Medicaid
1923944OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LABT2207276OtherDEA #
LA1120830001Medicare NSC