Provider Demographics
NPI:1588799779
Name:CLINIC DRUG STORE OF GOLDEN MEADOW INC
Entity type:Organization
Organization Name:CLINIC DRUG STORE OF GOLDEN MEADOW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CALLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:985-475-7777
Mailing Address - Street 1:110 S BAYOU DR
Mailing Address - Street 2:
Mailing Address - City:GOLDEN MEADOW
Mailing Address - State:LA
Mailing Address - Zip Code:70357-2728
Mailing Address - Country:US
Mailing Address - Phone:985-475-7777
Mailing Address - Fax:985-475-7888
Practice Address - Street 1:110 SOUTH BAYOU DRIVE
Practice Address - Street 2:
Practice Address - City:GOLDEN MEADOW
Practice Address - State:LA
Practice Address - Zip Code:70357
Practice Address - Country:US
Practice Address - Phone:985-475-7777
Practice Address - Fax:985-475-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1209538Medicaid
LA19-15480OtherNABP NUMBER
LAAC6391243OtherSTORE DEA NUMBER