Provider Demographics
NPI:1568640902
Name:LEE ROAD DRUGS
Entity Type:Organization
Organization Name:LEE ROAD DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:KRYJAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:985-982-4800
Mailing Address - Street 1:19705 HIGHWAY 40
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70435-9316
Mailing Address - Country:US
Mailing Address - Phone:985-892-4800
Mailing Address - Fax:985-871-8833
Practice Address - Street 1:19705 HIGHWAY 40
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70435-9316
Practice Address - Country:US
Practice Address - Phone:985-892-4800
Practice Address - Fax:985-871-8833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEE ROAD DRUGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271268Medicaid