Provider Demographics
NPI:1134116742
Name:PONTCHARTRAIN PHARMACY, LLC
Entity Type:Organization
Organization Name:PONTCHARTRAIN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:985-626-1900
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0399
Mailing Address - Country:US
Mailing Address - Phone:985-626-9726
Mailing Address - Fax:985-626-7919
Practice Address - Street 1:2045 HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-1909
Practice Address - Country:US
Practice Address - Phone:985-626-9726
Practice Address - Fax:985-626-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1270-IR3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1234460Medicaid
LA1234460Medicaid