MEDICARE: CHILDREN'S PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PHY-007098-IR	LA

General Provider Information

NPI Number	:	1184019846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDREN'S PHARMACY

Provider Business Mailing Address
First Line	:	4111 LAKE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-4305
Country	:	US
Telephone Number	:	337-502-4873
Fax Number	:

Provider Business Practice Location Address
First Line	:	4111 LAKE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-4305
Country	:	US
Telephone Number	:	337-502-4873
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CHUCK K. SELF
Credential	:	ADMINISTRATOR
Telephone Number	:	337-478-6480

Provider Enumeration Date	:	03/31/2015
Last Update Date	:	03/31/2015

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Directions to “CHILDREN'S PHARMACY ” Practice Location

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