Provider Demographics
NPI:1679519607
Name:DUTCHTOWN PHARMACY L L C
Entity Type:Organization
Organization Name:DUTCHTOWN PHARMACY L L C
Other - Org Name:DUTCHTOWN PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TINNERELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-320-5175
Mailing Address - Street 1:1812 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2945
Mailing Address - Country:US
Mailing Address - Phone:225-677-5070
Mailing Address - Fax:225-673-5060
Practice Address - Street 1:13011 HIGHWAY 73
Practice Address - Street 2:
Practice Address - City:GEISMAR
Practice Address - State:LA
Practice Address - Zip Code:70734-3021
Practice Address - Country:US
Practice Address - Phone:225-677-5070
Practice Address - Fax:225-673-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY-005662-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035369OtherPK
6360350001Medicare NSC