Provider Demographics
NPI:1417341413
Name:MALL PHARMACY LLC
Entity Type:Organization
Organization Name:MALL PHARMACY LLC
Other - Org Name:MALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:OGLEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:318-539-3622
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075-1126
Mailing Address - Country:US
Mailing Address - Phone:318-539-3622
Mailing Address - Fax:318-539-5189
Practice Address - Street 1:531 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-4027
Practice Address - Country:US
Practice Address - Phone:318-539-3622
Practice Address - Fax:318-539-5189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY.007009IR3336C0003X
LAPHY.007009-IR3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy