Provider Demographics
NPI:1477083590
Name:HENDERSON PHARMACY
Entity Type:Organization
Organization Name:HENDERSON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-645-6116
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:ZWOLLE
Mailing Address - State:LA
Mailing Address - Zip Code:71486-0608
Mailing Address - Country:US
Mailing Address - Phone:318-645-6116
Mailing Address - Fax:318-645-2209
Practice Address - Street 1:1169 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ZWOLLE
Practice Address - State:LA
Practice Address - Zip Code:71486-3501
Practice Address - Country:US
Practice Address - Phone:318-645-6116
Practice Address - Fax:318-645-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY.000449-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1904728Medicaid