Provider Demographics
NPI:1295871804
Name:NIELSEN'S CITY DRUG STORE, INC
Entity type:Organization
Organization Name:NIELSEN'S CITY DRUG STORE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-732-2561
Mailing Address - Street 1:330 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3818
Mailing Address - Country:US
Mailing Address - Phone:985-732-2561
Mailing Address - Fax:985-732-3421
Practice Address - Street 1:330 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3818
Practice Address - Country:US
Practice Address - Phone:985-732-2562
Practice Address - Fax:985-732-3421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
LAPHY.000821-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1231398Medicaid
2028619OtherPK
1188240001Medicare NSC
1188240001Medicare NSC