Provider Demographics
NPI:1750327110
Name:RIVER ROAD DISCOUNT PHARMACY
Entity Type:Organization
Organization Name:RIVER ROAD DISCOUNT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/AUTHORIZED REP
Authorized Official - Prefix:
Authorized Official - First Name:TRENIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-431-7647
Mailing Address - Street 1:6243 RIVER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:AVONDALE
Mailing Address - State:LA
Mailing Address - Zip Code:70094-2647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6243 RIVER RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:LA
Practice Address - Zip Code:70094-2647
Practice Address - Country:US
Practice Address - Phone:504-431-7647
Practice Address - Fax:504-431-7650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAC005573IR333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932690OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LA1233846Medicaid