Provider Demographics
NPI:1306837141
Name:EDDIE'S PHARMACY, INC.
Entity Type:Organization
Organization Name:EDDIE'S PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER/CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:EDDIE
Authorized Official - Last Name:BORDELON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-876-3665
Mailing Address - Street 1:206 CHOUPIQUE LN
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-3757
Mailing Address - Country:US
Mailing Address - Phone:318-876-3665
Mailing Address - Fax:318-876-3665
Practice Address - Street 1:206 CHOUPIQUE LN
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327-3757
Practice Address - Country:US
Practice Address - Phone:318-876-3665
Practice Address - Fax:318-876-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1692-IR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1253626Medicaid
LA1919337OtherNABP
LAAE1635210OtherDEA - US DEPT. OF JUSTICE