Provider Demographics
NPI:1922174689
Name:JEFFERSON PHARMACY,LLC
Entity Type:Organization
Organization Name:JEFFERSON PHARMACY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:DJAPNI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:337-255-4238
Mailing Address - Street 1:620 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501
Mailing Address - Country:US
Mailing Address - Phone:337-234-1428
Mailing Address - Fax:337-234-1429
Practice Address - Street 1:620 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7206
Practice Address - Country:US
Practice Address - Phone:337-234-1428
Practice Address - Fax:337-234-1429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY006926IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2207113Medicaid
LA2202839Medicaid