Provider Demographics
NPI:1881871333
Name:IBERIA COMPREHENSIVE CHC PHARMACY
Entity type:Organization
Organization Name:IBERIA COMPREHENSIVE CHC PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTTE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-376-6868
Mailing Address - Street 1:806 JEFFERSON TER
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5727
Mailing Address - Country:US
Mailing Address - Phone:337-376-6868
Mailing Address - Fax:337-376-6866
Practice Address - Street 1:806 JEFFERSON TER
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-5727
Practice Address - Country:US
Practice Address - Phone:337-376-6868
Practice Address - Fax:337-376-6866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA59873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035620OtherPK