Provider Demographics
NPI:1467755264
Name:CCC PHARMACY LLC
Entity Type:Organization
Organization Name:CCC PHARMACY LLC
Other - Org Name:FUSIONCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ROBICHAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-445-8770
Mailing Address - Street 1:180 WINDERMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3535
Mailing Address - Country:US
Mailing Address - Phone:318-445-8770
Mailing Address - Fax:318-445-8979
Practice Address - Street 1:180 WINDERMERE BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3535
Practice Address - Country:US
Practice Address - Phone:318-445-8770
Practice Address - Fax:318-445-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY006277-IR332B00000X
LAPHY-0622IR3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2200216Medicaid