Provider Demographics
NPI:1609936012
Name:MONROE MEDICAL CLINIC PHARMACY
Entity Type:Organization
Organization Name:MONROE MEDICAL CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-322-0319
Mailing Address - Street 1:100 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-8537
Mailing Address - Country:US
Mailing Address - Phone:318-322-0319
Mailing Address - Fax:
Practice Address - Street 1:100 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-8537
Practice Address - Country:US
Practice Address - Phone:318-322-0319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15546183500000X
LA4928 IR251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No251G00000XAgenciesHospice Care, Community BasedGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1269654Medicaid
LA1269654Medicaid