Provider Demographics
NPI:1164565933
Name:BLAKES SOUTHSIDE PHARMACY PHASE II LLC
Entity Type:Organization
Organization Name:BLAKES SOUTHSIDE PHARMACY PHASE II LLC
Other - Org Name:BLAKES SOUTHSIDE PHARMACY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PIC ( PHARMACIST IN CHARGE)
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORET
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:337-363-7497
Mailing Address - Street 1:808 S. CHATAIGNIER RD
Mailing Address - Street 2:
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586
Mailing Address - Country:US
Mailing Address - Phone:337-363-7497
Mailing Address - Fax:337-363-0473
Practice Address - Street 1:808 S. CHATAIGNIER RD
Practice Address - Street 2:
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586
Practice Address - Country:US
Practice Address - Phone:337-363-7497
Practice Address - Fax:337-363-0473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10232183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1252620Medicaid