Provider Demographics
NPI:1407282585
Name:FOUNTAIN PARK PHARMACY INC.
Entity Type:Organization
Organization Name:FOUNTAIN PARK PHARMACY INC.
Other - Org Name:FOUNTAIN PARK PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JO STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CULOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:504-434-4777
Mailing Address - Street 1:1901 MANHATTAN BLVD
Mailing Address - Street 2:BUILDING F SUITE 104
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-3582
Mailing Address - Country:US
Mailing Address - Phone:504-434-4777
Mailing Address - Fax:504-309-8031
Practice Address - Street 1:1901 MANHATTAN BLVD
Practice Address - Street 2:BUILDING F SUITE 104
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-3582
Practice Address - Country:US
Practice Address - Phone:504-434-4777
Practice Address - Fax:504-309-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY007141IR333600000X
KYLA1845333600000X
AL114250333600000X
TN5277333600000X
MS14022/7.1333600000X
SC15677333600000X
KS22-44626333600000X
FLPH272073336C0003X
GAPHNR0007023336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142276OtherPK
LA2204238Medicaid