Provider Demographics
NPI:1265538664
Name:POLKS CROSSGATES DISCOUNT DRUGS INC
Entity type:Organization
Organization Name:POLKS CROSSGATES DISCOUNT DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-429-0161
Mailing Address - Street 1:2255 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3547
Mailing Address - Country:US
Mailing Address - Phone:318-429-0161
Mailing Address - Fax:318-429-0163
Practice Address - Street 1:2255 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3547
Practice Address - Country:US
Practice Address - Phone:318-429-0161
Practice Address - Fax:318-429-0163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5223332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271357Medicaid
OK200022580AMedicaid
TX580101Medicaid
LA1271357Medicaid