Provider Demographics
NPI:1649256058
Name:WELLNECESSITIES PHARMACY LAB
Entity type:Organization
Organization Name:WELLNECESSITIES PHARMACY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPOUNDING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KALSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RPH
Authorized Official - Phone:318-222-0885
Mailing Address - Street 1:8835 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6718
Mailing Address - Country:US
Mailing Address - Phone:318-222-0885
Mailing Address - Fax:318-861-7431
Practice Address - Street 1:8835 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6718
Practice Address - Country:US
Practice Address - Phone:318-222-0885
Practice Address - Fax:318-861-7431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271969Medicaid