Provider Demographics
NPI:1740726124
Name:AMKG LLC
Entity type:Organization
Organization Name:AMKG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-683-8195
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0966
Mailing Address - Country:US
Mailing Address - Phone:225-683-8195
Mailing Address - Fax:225-683-9826
Practice Address - Street 1:1169 HWY 19
Practice Address - Street 2:
Practice Address - City:SLAUGHTER
Practice Address - State:LA
Practice Address - Zip Code:70777
Practice Address - Country:US
Practice Address - Phone:225-286-7773
Practice Address - Fax:225-286-4833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
LAPHY.007445-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168061OtherPK