MEDICARE: PORT VINCENT PHARMACY LLC

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1518193051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT VINCENT PHARMACY LLC

Provider Business Mailing Address
First Line	:	18590 LA HIGHWAY 16
Second Line	:	SUITE 1
City	:	PORT VINCENT
State	:	LA
Zip	:	70726-8066
Country	:	US
Telephone Number	:	225-698-6666
Fax Number	:	225-698-6766

Provider Business Practice Location Address
First Line	:	18590 LA HIGHWAY 16
Second Line	:	SUITE 1
City	:	PORT VINCENT
State	:	LA
Zip	:	70726-8066
Country	:	US
Telephone Number	:	225-698-6666
Fax Number	:	225-698-6766

Authorized Official
Title or Position	:	OWNER/PHARMACIST-IN-CHARGE
Name	:	MR. MERLIN ANTHONY LACOMBE JR.
Credential	:	R.PH.
Telephone Number	:	225-698-6666

Provider Enumeration Date	:	06/10/2009
Last Update Date	:	06/10/2009

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Directions to “PORT VINCENT PHARMACY LLC ” Practice Location

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