Provider Demographics
NPI:1477725638
Name:PONCHATOULA FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:PONCHATOULA FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:MERCANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-386-0361
Mailing Address - Street 1:1812 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-2945
Mailing Address - Country:US
Mailing Address - Phone:985-386-6556
Mailing Address - Fax:985-386-6552
Practice Address - Street 1:19008 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-6780
Practice Address - Country:US
Practice Address - Phone:985-386-6556
Practice Address - Fax:985-386-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1224758Medicaid