Provider Demographics
NPI:1952676124
Name:AFFINITY HEALTH GROUP LLC
Entity Type:Organization
Organization Name:AFFINITY HEALTH GROUP LLC
Other - Org Name:SAINT JOHN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:318-807-1083
Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-1083
Mailing Address - Fax:318-807-1079
Practice Address - Street 1:122 SAINT JOHN ST STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7370
Practice Address - Country:US
Practice Address - Phone:318-807-1083
Practice Address - Fax:318-807-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336M0002X
LAPHY.006513-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134987OtherPK
LA2201441Medicaid