Provider Demographics
NPI:1578677555
Name:VALENTINE PHARMACY INC
Entity Type:Organization
Organization Name:VALENTINE PHARMACY INC
Other - Org Name:VALENTINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONNY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-872-5300
Mailing Address - Street 1:PO BOX 1619
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-1619
Mailing Address - Country:US
Mailing Address - Phone:318-872-5300
Mailing Address - Fax:318-872-3968
Practice Address - Street 1:116 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2602
Practice Address - Country:US
Practice Address - Phone:318-872-5300
Practice Address - Fax:318-872-5380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
LA27203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1261076Medicaid
1924821OtherNCPDP PROVIDER IDENTIFICATION NUMBER
LA1261076Medicaid