Provider Demographics
NPI:1770648677
Name:WHITE'S COMPOUNDING PHARMACY, LLC
Entity Type:Organization
Organization Name:WHITE'S COMPOUNDING PHARMACY, LLC
Other - Org Name:BOUDREAUX'S SPECIALTY COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-631-2005
Mailing Address - Street 1:2551 GREENWOOD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3981
Mailing Address - Country:US
Mailing Address - Phone:318-631-2005
Mailing Address - Fax:318-631-1883
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-631-2005
Practice Address - Fax:318-631-1883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4242-IR183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1267171Medicaid