Provider Demographics
NPI:1518193051
Name:PORT VINCENT PHARMACY LLC
Entity Type:Organization
Organization Name:PORT VINCENT PHARMACY LLC
Other - Org Name:PORT VINCENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:MERLIN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LACOMBE
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:225-698-6666
Mailing Address - Street 1:18590 LA HIGHWAY 16
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT VINCENT
Mailing Address - State:LA
Mailing Address - Zip Code:70726-8066
Mailing Address - Country:US
Mailing Address - Phone:225-698-6666
Mailing Address - Fax:225-698-6766
Practice Address - Street 1:18590 LA HIGHWAY 16
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT VINCENT
Practice Address - State:LA
Practice Address - Zip Code:70726-8066
Practice Address - Country:US
Practice Address - Phone:225-698-6666
Practice Address - Fax:225-698-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy