Provider Demographics
NPI:1811037294
Name:GRAND COTEAU PRESCRIPTION SHOPPE & GROCERY INC.
Entity Type:Organization
Organization Name:GRAND COTEAU PRESCRIPTION SHOPPE & GROCERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-662-5777
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:GRAND COTEAU
Mailing Address - State:LA
Mailing Address - Zip Code:70541-1200
Mailing Address - Country:US
Mailing Address - Phone:337-662-5777
Mailing Address - Fax:337-662-5789
Practice Address - Street 1:512 MARTIN LUTHER KING JR. DR.
Practice Address - Street 2:
Practice Address - City:GRAND COTEAU
Practice Address - State:LA
Practice Address - Zip Code:70541
Practice Address - Country:US
Practice Address - Phone:337-662-5777
Practice Address - Fax:337-662-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1889-IR183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANCPDPOther1920746