Provider Demographics
NPI:1508112889
Name:MACK BAYOU PHARMACY LLC
Entity Type:Organization
Organization Name:MACK BAYOU PHARMACY LLC
Other - Org Name:MACK BAYOU PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:850-622-0730
Mailing Address - Street 1:82 MACK BAYOU LOOP STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-2607
Mailing Address - Country:US
Mailing Address - Phone:850-622-0730
Mailing Address - Fax:850-622-0755
Practice Address - Street 1:82 MACK BAYOU LOOP STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-2607
Practice Address - Country:US
Practice Address - Phone:850-622-0730
Practice Address - Fax:850-622-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
FLPH263213336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137562OtherPK