Provider Demographics
NPI:1700979143
Name:CROSSROADS PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:CROSSROADS PHARMACY SERVICES LLC
Other - Org Name:CROSSROADS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-539-3199
Mailing Address - Street 1:27 REYNOLDS STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075
Mailing Address - Country:US
Mailing Address - Phone:318-443-3100
Mailing Address - Fax:318-443-3635
Practice Address - Street 1:3592 HIGHWAY 28 E
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-5816
Practice Address - Country:US
Practice Address - Phone:318-443-3100
Practice Address - Fax:318-443-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
LAPHY.007478-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2205307Medicaid
2035279OtherPK