MEDICARE: HEALTH MART OF JENNINGS 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	3336C0004X	Compounding Pharmacy
2	333600000X	Pharmacy
3	3336L0003X	Long Term Care Pharmacy
4	3336C0003X	Community/Retail Pharmacy	PHY.005639-IR	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2035363	OTHER		PK

General Provider Information

NPI Number	:	1669403697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH MART OF JENNINGS LLC

Provider Business Mailing Address
First Line	:	818 N CUSHING AVE
Second Line	:
City	:	KAPLAN
State	:	LA
Zip	:	70548-2615
Country	:	US
Telephone Number	:	337-643-7952
Fax Number	:	337-643-7953

Provider Business Practice Location Address
First Line	:	1322 ELTON RD
Second Line	:	SUITE A
City	:	JENNINGS
State	:	LA
Zip	:	70546-4100
Country	:	US
Telephone Number	:	337-616-9500
Fax Number	:	337-616-9555

Authorized Official
Title or Position	:	OWNER AND PRESIDENT
Name	:	WESLEY DAVID
Credential	:	RPH
Telephone Number	:	337-616-9500

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	12/22/2015

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Directions to “HEALTH MART OF JENNINGS LLC ” Practice Location

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