Provider Demographics
NPI:1639670672
Name:JEANSONNE FAMILY PHARMACY, LLC
Entity Type:Organization
Organization Name:JEANSONNE FAMILY PHARMACY, LLC
Other - Org Name:JEANSONNE FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEANSONNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-264-0512
Mailing Address - Street 1:521 ASBURY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471
Mailing Address - Country:US
Mailing Address - Phone:985-951-2688
Mailing Address - Fax:985-951-2691
Practice Address - Street 1:521 ASBURY DRIVE
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471
Practice Address - Country:US
Practice Address - Phone:985-951-2688
Practice Address - Fax:985-951-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2205633Medicaid