Provider Demographics
NPI:1275592446
Name:MELANCON PHARMACY INC
Entity Type:Organization
Organization Name:MELANCON PHARMACY INC
Other - Org Name:MELANCON PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-896-8434
Mailing Address - Street 1:730 VETERANS DR
Mailing Address - Street 2:STE A
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-3619
Mailing Address - Country:US
Mailing Address - Phone:337-896-8435
Mailing Address - Fax:337-896-4654
Practice Address - Street 1:730 VETERANS DR STE A
Practice Address - Street 2:STE A
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-3619
Practice Address - Country:US
Practice Address - Phone:337-896-8435
Practice Address - Fax:337-896-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336I0012X
LAPHY-005875-IR3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1215350Medicaid
2035173OtherPK