Provider Demographics
NPI:1790280717
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:KIITZKE
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:2018-03-30
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPHY.006459-IR3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2201174Medicaid