Provider Demographics
NPI:1538288113
Name:TED S PHARMACY LLC
Entity Type:Organization
Organization Name:TED S PHARMACY LLC
Other - Org Name:TED'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-624-1053
Mailing Address - Street 1:1866 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAYNESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71038-4904
Mailing Address - Country:US
Mailing Address - Phone:318-624-1053
Mailing Address - Fax:318-624-2233
Practice Address - Street 1:1866 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYNESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71038-4904
Practice Address - Country:US
Practice Address - Phone:318-624-1053
Practice Address - Fax:318-624-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
LAPHY.005750-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2029769OtherPK
LA1269719Medicaid