Provider Demographics
NPI:1942583166
Name:LANDRY COLHAM LLC
Entity Type:Organization
Organization Name:LANDRY COLHAM LLC
Other - Org Name:BRENT'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-332-0511
Mailing Address - Street 1:243 N ACADIAN THRUWAY STE 1
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3772
Mailing Address - Country:US
Mailing Address - Phone:225-332-0511
Mailing Address - Fax:225-332-5811
Practice Address - Street 1:243 N ACADIAN THRUWAY STE 1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3772
Practice Address - Country:US
Practice Address - Phone:225-332-0511
Practice Address - Fax:225-332-5811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
LAPHY.0064223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2200950Medicaid
2132484OtherPK