Provider Demographics
NPI:1568510030
Name:IDEAL HEALTH MART PHARMACY INC
Entity Type:Organization
Organization Name:IDEAL HEALTH MART PHARMACY INC
Other - Org Name:IDEAL HEALTH MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KESA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-463-7210
Mailing Address - Street 1:610 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-3546
Mailing Address - Country:US
Mailing Address - Phone:337-463-7210
Mailing Address - Fax:337-462-0930
Practice Address - Street 1:610 N PINE ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-3546
Practice Address - Country:US
Practice Address - Phone:337-463-7210
Practice Address - Fax:337-462-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006477333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1902801OtherNCPDP PROVIDER IDENTIFICATION NUMBER
LA2201344Medicaid
1902801OtherNCPDP PROVIDER IDENTIFICATION NUMBER