Provider Demographics
NPI:1790827897
Name:ROBERT B VIDRINE BLAKES FAMILY PHARMACY
Entity Type:Organization
Organization Name:ROBERT B VIDRINE BLAKES FAMILY PHARMACY
Other - Org Name:BLAKES FAMILY PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:VIDRINE
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:337-363-6252
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:512 MC ARTHUR DR
Mailing Address - City:VILLE PLATTE
Mailing Address - State:LA
Mailing Address - Zip Code:70586-0348
Mailing Address - Country:US
Mailing Address - Phone:337-363-6252
Mailing Address - Fax:337-363-0477
Practice Address - Street 1:512 MCARTHUR DR.
Practice Address - Street 2:
Practice Address - City:VILLE PLATTE
Practice Address - State:LA
Practice Address - Zip Code:70586-2906
Practice Address - Country:US
Practice Address - Phone:337-363-6252
Practice Address - Fax:337-363-0477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1204471Medicaid