Provider Demographics
NPI:1629172689
Name:HAYDELS DRUG STORE INC
Entity Type:Organization
Organization Name:HAYDELS DRUG STORE INC
Other - Org Name:HAYDELS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:985-879-2440
Mailing Address - Street 1:4752 HIGHWAY 311 STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2810
Mailing Address - Country:US
Mailing Address - Phone:985-879-2440
Mailing Address - Fax:985-879-2967
Practice Address - Street 1:4752 HIGHWAY 311 STE 100
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2810
Practice Address - Country:US
Practice Address - Phone:985-879-2440
Practice Address - Fax:985-879-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY000451IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1219606Medicaid
2028736OtherPK