Provider Demographics
NPI:1891916235
Name:THIBODEAUX'S PHARMACY INC.
Entity Type:Organization
Organization Name:THIBODEAUX'S PHARMACY INC.
Other - Org Name:THIBODEAUX'S PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:337-536-6115
Mailing Address - Street 1:104 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUEYDAN
Mailing Address - State:LA
Mailing Address - Zip Code:70542-3528
Mailing Address - Country:US
Mailing Address - Phone:337-536-6115
Mailing Address - Fax:
Practice Address - Street 1:104 MAIN ST
Practice Address - Street 2:
Practice Address - City:GUEYDAN
Practice Address - State:LA
Practice Address - Zip Code:70542-3528
Practice Address - Country:US
Practice Address - Phone:337-536-6115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13125183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1260622Medicaid