Provider Demographics
NPI:1346352200
Name:WATERPROOF DRUGS INC
Entity Type:Organization
Organization Name:WATERPROOF DRUGS INC
Other - Org Name:COLVINS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-757-4114
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-0669
Mailing Address - Country:US
Mailing Address - Phone:318-757-4114
Mailing Address - Fax:318-757-4111
Practice Address - Street 1:114 SERIO BLVD
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2013
Practice Address - Country:US
Practice Address - Phone:318-757-4114
Practice Address - Fax:318-757-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.001842-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1254932Medicaid
2031236OtherPK