Provider Demographics
NPI:1659417202
Name:CANNONS DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:CANNONS DISCOUNT PHARMACY LLC
Other - Org Name:CANNONS DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANG
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:504-415-7595
Mailing Address - Street 1:182 W 3RD ST
Mailing Address - Street 2:BLDG. A
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-7056
Mailing Address - Country:US
Mailing Address - Phone:504-667-4433
Mailing Address - Fax:504-539-3716
Practice Address - Street 1:13351 E ALESSI RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2398
Practice Address - Country:US
Practice Address - Phone:985-878-5555
Practice Address - Fax:985-878-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336M0002X
LAPHY.005972-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1268798Medicaid
2035430OtherPK
LA1227901Medicaid
LA1268798Medicaid