Provider Demographics
NPI:1689077430
Name:UNIVERSITY HEALTH SHREVEPORT LLC
Entity Type:Organization
Organization Name:UNIVERSITY HEALTH SHREVEPORT LLC
Other - Org Name:UNIVERSITY HEALTH SHREVEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-626-0454
Mailing Address - Street 1:1541 KINGS HWY
Mailing Address - Street 2:ATTN: PHARMACY RM AG-13
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-626-0863
Mailing Address - Fax:318-626-3222
Practice Address - Street 1:1606 KINGS HWY RM 2263
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4128
Practice Address - Country:US
Practice Address - Phone:318-626-0454
Practice Address - Fax:318-626-3222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148172OtherPK