Provider Demographics
NPI:1336253319
Name:BRODIE PHARMACY INC
Entity Type:Organization
Organization Name:BRODIE PHARMACY INC
Other - Org Name:BRODIE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-647-5754
Mailing Address - Street 1:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:MER ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:71261-0153
Mailing Address - Country:US
Mailing Address - Phone:318-647-5754
Mailing Address - Fax:318-647-5222
Practice Address - Street 1:204 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:MER ROUGE
Practice Address - State:LA
Practice Address - Zip Code:71261
Practice Address - Country:US
Practice Address - Phone:318-647-5754
Practice Address - Fax:318-647-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
LA000103IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1205800Medicaid
1907510OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1907510OtherNCPDP PROVIDER IDENTIFICATION NUMBER