Provider Demographics
NPI:1750446183
Name:LAKE CHARLES PHARMACEUTICAL SUPPLY COMPANY LLC
Entity Type:Organization
Organization Name:LAKE CHARLES PHARMACEUTICAL SUPPLY COMPANY LLC
Other - Org Name:MEDICAL PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JOINER
Authorized Official - Last Name:SALTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-494-2990
Mailing Address - Street 1:1717 OAK PARK BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8977
Mailing Address - Country:US
Mailing Address - Phone:337-494-2990
Mailing Address - Fax:337-494-2550
Practice Address - Street 1:1717 OAK PARK BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8977
Practice Address - Country:US
Practice Address - Phone:337-494-2990
Practice Address - Fax:337-494-2550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST LOUISIANA HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-26
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133790OtherPK
LA2206842Medicaid
LA007810-IROtherBOARD OF PHARMACY