Provider Demographics
NPI:1922372358
Name:COTTONPORT CORNER DRUG LLC
Entity Type:Organization
Organization Name:COTTONPORT CORNER DRUG LLC
Other - Org Name:COTTONPORT CORNER DRUG LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MRS.
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-253-2399
Mailing Address - Street 1:206 CHOUPIQUE LN
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-3757
Mailing Address - Country:US
Mailing Address - Phone:318-876-3665
Mailing Address - Fax:318-876-2429
Practice Address - Street 1:206 CHOUPIQUE LN
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327-3757
Practice Address - Country:US
Practice Address - Phone:318-876-3665
Practice Address - Fax:318-876-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006498-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134437OtherPK
LA2201336Medicaid