Provider Demographics
NPI:1578661013
Name:PHOENIX REXALL DRUGS, INC DBA PHOENIX HOME MEDICAL
Entity Type:Organization
Organization Name:PHOENIX REXALL DRUGS, INC DBA PHOENIX HOME MEDICAL
Other - Org Name:PHOENIX HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:WANN-JEANE
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:337-238-5114
Mailing Address - Street 1:PO BOX 172
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71496-0172
Mailing Address - Country:US
Mailing Address - Phone:337-238-5114
Mailing Address - Fax:337-239-9200
Practice Address - Street 1:100 E FERTITTA BLVD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4737
Practice Address - Country:US
Practice Address - Phone:337-238-5114
Practice Address - Fax:337-239-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336H0001X
LA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC8065OtherBLUE CROSS FOR DME
LA2365801Medicaid
LAG7560OtherBLUE CROSS IV #
LAG7560OtherBLUE CROSS IV #