Provider Demographics
NPI:1134145295
Name:KAY'S HIDEAWAY PHARMACY, INC.
Entity Type:Organization
Organization Name:KAY'S HIDEAWAY PHARMACY, INC.
Other - Org Name:VITAL CARE OF NORTHEAST LA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-343-4663
Mailing Address - Street 1:4140 OLD STERLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2629
Mailing Address - Country:US
Mailing Address - Phone:318-343-4777
Mailing Address - Fax:318-343-4691
Practice Address - Street 1:4140 OLD STERLINGTON RD
Practice Address - Street 2:STE 3
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2629
Practice Address - Country:US
Practice Address - Phone:318-343-4663
Practice Address - Fax:317-343-4691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3929 IR332B00000X, 332BP3500X, 333600000X, 3336H0001X
LA3929-IR3336C0003X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1265870Medicaid
LA=========BOtherBCBS HIT
=========002OtherTRICARE CSP
=========AOtherBCBS DME
=========002OtherTRICARE CSP