Provider Demographics
NPI:1811219827
Name:POINCIANA PHARMACY LLC
Entity Type:Organization
Organization Name:POINCIANA PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:TRIPLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-468-5001
Mailing Address - Street 1:1508 CAJUN DR
Mailing Address - Street 2:STE A
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554-2400
Mailing Address - Country:US
Mailing Address - Phone:337-468-5001
Mailing Address - Fax:337-468-5102
Practice Address - Street 1:1508 CAJUN DR
Practice Address - Street 2:STE A
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554-2400
Practice Address - Country:US
Practice Address - Phone:337-468-5001
Practice Address - Fax:337-468-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-17
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006222-IR3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1235598Medicaid
2123858OtherPK