Provider Demographics
NPI:1174008064
Name:PROVINCE PHARMACY INC
Entity Type:Organization
Organization Name:PROVINCE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:337-534-0315
Mailing Address - Street 1:5000 AMBASSADOR CAFFERY PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6984
Mailing Address - Country:US
Mailing Address - Phone:337-534-0315
Mailing Address - Fax:337-534-0616
Practice Address - Street 1:5000 AMBASSADOR CAFFERY PKWY STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6984
Practice Address - Country:US
Practice Address - Phone:337-534-0315
Practice Address - Fax:337-534-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy