Provider Demographics
NPI:1891195467
Name:MANSFIELD DRUG INC
Entity Type:Organization
Organization Name:MANSFIELD DRUG INC
Other - Org Name:MANSFIELD DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-872-1933
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-1329
Mailing Address - Country:US
Mailing Address - Phone:318-872-1933
Mailing Address - Fax:318-872-5816
Practice Address - Street 1:132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2602
Practice Address - Country:US
Practice Address - Phone:318-872-1933
Practice Address - Fax:318-872-5816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY006935IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2202979Medicaid
2147678OtherPK
LA2202979Medicaid