Provider Demographics
NPI:1770551277
Name:MELANCON PHARMACY INC
Entity type:Organization
Organization Name:MELANCON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:337-896-8434
Mailing Address - Street 1:730 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-3619
Mailing Address - Country:US
Mailing Address - Phone:337-896-8434
Mailing Address - Fax:337-896-4654
Practice Address - Street 1:730 VETERANS DR
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-3619
Practice Address - Country:US
Practice Address - Phone:337-896-8434
Practice Address - Fax:337-896-4454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X
LA58743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1214159Medicaid
2028631OtherPK
LA1214159Medicaid