Provider Demographics
NPI:1346576600
Name:IBERVILLE MEDICAL SUPPLIES STORE, LLC
Entity Type:Organization
Organization Name:IBERVILLE MEDICAL SUPPLIES STORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAGGENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-385-3155
Mailing Address - Street 1:58610 BELLEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-3900
Mailing Address - Country:US
Mailing Address - Phone:225-385-3155
Mailing Address - Fax:225-687-6311
Practice Address - Street 1:58610 BELLEVIEW DR
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3900
Practice Address - Country:US
Practice Address - Phone:225-385-3155
Practice Address - Fax:225-687-6311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies