Provider Demographics
NPI:1619058468
Name:LINE AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:LINE AVENUE PHARMACY INC
Other - Org Name:SHREVEPORT NUCLEAR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:CAUDLE
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:318-221-5114
Mailing Address - Street 1:1822 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4612
Mailing Address - Country:US
Mailing Address - Phone:318-221-5114
Mailing Address - Fax:318-221-5137
Practice Address - Street 1:1822 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4612
Practice Address - Country:US
Practice Address - Phone:318-221-5114
Practice Address - Fax:318-221-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 3999-IR3336C0003X
LALA 4001-NU3336N0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336N0007XSuppliersPharmacyNuclear Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1266841Medicaid
LA1266841Medicaid