Provider Demographics
NPI:1942397666
Name:COURT HOUSE PHARMACY
Entity Type:Organization
Organization Name:COURT HOUSE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRIAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-628-3303
Mailing Address - Street 1:104 S JONES ST
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483
Mailing Address - Country:US
Mailing Address - Phone:318-628-3303
Mailing Address - Fax:318-628-7122
Practice Address - Street 1:104 S JONES ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483
Practice Address - Country:US
Practice Address - Phone:318-628-3303
Practice Address - Fax:318-628-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201IR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1211001Medicaid
1911886OtherNCPDP
1911886OtherNCPDP