Provider Demographics
NPI:1619993300
Name:VITAL CARE OF MISS-LOU INC
Entity Type:Organization
Organization Name:VITAL CARE OF MISS-LOU INC
Other - Org Name:LAKESIDE PHARMACY & GIFT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:R.PH.
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-386-2344
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:LA
Mailing Address - Zip Code:71354-0037
Mailing Address - Country:US
Mailing Address - Phone:318-386-2344
Mailing Address - Fax:318-386-2366
Practice Address - Street 1:6280 HIGHWAY 129
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:LA
Practice Address - Zip Code:71354-4072
Practice Address - Country:US
Practice Address - Phone:318-386-2344
Practice Address - Fax:318-386-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
LAPHY.007013-IR3336C0003X
LA332B00000X, 3336L0003X
LA2627-IR3336M0002X, 3336S0011X
LA2627 IR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203754Medicaid
2033948OtherPK
2033948OtherPK
0478890001Medicare NSC
LA2203754Medicaid
MS08325235Medicaid
MS04477327Medicaid
1928564OtherNABP