Provider Demographics
NPI:1457348641
Name:ACADIANA PHARMACEUTICAL MEDICAL LLC
Entity Type:Organization
Organization Name:ACADIANA PHARMACEUTICAL MEDICAL LLC
Other - Org Name:LIFEHOUSE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY LLC MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:REYBURN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:251-945-1540
Mailing Address - Street 1:22203 A HWY 59
Mailing Address - Street 2:
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567
Mailing Address - Country:US
Mailing Address - Phone:251-945-1540
Mailing Address - Fax:251-945-1542
Practice Address - Street 1:22203 A HWY 59
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567
Practice Address - Country:US
Practice Address - Phone:251-945-1540
Practice Address - Fax:251-945-1542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL112604333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0132833OtherNCPDP
0132833OtherNCPDP