Provider Demographics
NPI:1225800733
Name:MAIN STREET PHARMACY
Entity Type:Organization
Organization Name:MAIN STREET PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WITSCHEN
Authorized Official - Last Name:BRYCE
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
Authorized Official - Phone:225-451-5804
Mailing Address - Street 1:5500 FIRE STATION RD STE A
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7468
Mailing Address - Country:US
Mailing Address - Phone:225-451-5804
Mailing Address - Fax:
Practice Address - Street 1:5500 FIRE STATION RD STE A
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7468
Practice Address - Country:US
Practice Address - Phone:225-451-5804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy