Provider Demographics
NPI:1679857304
Name:COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:COMMUNITY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:KLITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-398-2100
Mailing Address - Street 1:2904 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3610
Mailing Address - Country:US
Mailing Address - Phone:318-398-2100
Mailing Address - Fax:318-387-7682
Practice Address - Street 1:2904 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3610
Practice Address - Country:US
Practice Address - Phone:318-398-2100
Practice Address - Fax:318-387-7682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY.006459-IR3336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2201174Medicaid
LA6657030001Medicare NSC