Provider Demographics
NPI:1184019846
Name:CHILDREN'S PHARMACY
Entity Type:Organization
Organization Name:CHILDREN'S PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:K
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:337-478-6480
Mailing Address - Street 1:4111 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4305
Mailing Address - Country:US
Mailing Address - Phone:337-502-4873
Mailing Address - Fax:
Practice Address - Street 1:4111 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4305
Practice Address - Country:US
Practice Address - Phone:337-502-4873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY-007098-IR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy