Provider Demographics
NPI:1366504169
Name:VAUGHANS CITY DRUGS OF CONCORDIA INC.
Entity Type:Organization
Organization Name:VAUGHANS CITY DRUGS OF CONCORDIA INC.
Other - Org Name:VAUGHANS CITY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-757-4811
Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334
Mailing Address - Country:US
Mailing Address - Phone:318-757-4811
Mailing Address - Fax:318-757-4439
Practice Address - Street 1:109 EE WALLACE BLVD N
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2819
Practice Address - Country:US
Practice Address - Phone:318-757-4811
Practice Address - Fax:318-757-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5305IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271993Medicaid
LA1271993Medicaid