Provider Demographics
NPI:1508396656
Name:BENNIE G. OWENS
Entity Type:Organization
Organization Name:BENNIE G. OWENS
Other - Org Name:HEADRICK'S DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-697-4381
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71049-0068
Mailing Address - Country:US
Mailing Address - Phone:318-697-4381
Mailing Address - Fax:
Practice Address - Street 1:204 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:LA
Practice Address - Zip Code:71049-2997
Practice Address - Country:US
Practice Address - Phone:318-697-4381
Practice Address - Fax:318-697-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA452-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX580009Medicaid
LA1219754Medicaid
1907116OtherNCPDP