Provider Demographics
NPI:1013912047
Name:DIXIE PHARMACY, INC.
Entity Type:Organization
Organization Name:DIXIE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:REITZELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-627-5428
Mailing Address - Street 1:615 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:LA
Mailing Address - Zip Code:71417-1414
Mailing Address - Country:US
Mailing Address - Phone:318-627-5428
Mailing Address - Fax:318-627-4187
Practice Address - Street 1:615 8TH ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:LA
Practice Address - Zip Code:71417-1414
Practice Address - Country:US
Practice Address - Phone:318-627-5428
Practice Address - Fax:318-627-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAR3413856333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1212903Medicaid
LA1904691OtherNCPDP
LA1904691OtherNCPDP
LAAR3413856OtherDEA NUMBER