Provider Demographics
NPI:1467484220
Name:HEALTH MART OF LAKE ARTHUR, INC.
Entity Type:Organization
Organization Name:HEALTH MART OF LAKE ARTHUR, INC.
Other - Org Name:HEALTH MART PHARMACY OF LAKE ARTHUR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-774-6622
Mailing Address - Street 1:500 N HIGHWAY 26
Mailing Address - Street 2:
Mailing Address - City:LAKE ARTHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70549-3904
Mailing Address - Country:US
Mailing Address - Phone:337-774-6622
Mailing Address - Fax:
Practice Address - Street 1:500 N HIGHWAY 26
Practice Address - Street 2:
Practice Address - City:LAKE ARTHUR
Practice Address - State:LA
Practice Address - Zip Code:70549-3904
Practice Address - Country:US
Practice Address - Phone:337-774-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2012-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1269549Medicaid
LA4976OtherLA BOARD OF PHARMACY PERMIT
LA4552240001Medicare NSC