Healthcare Provider Details

I. General information

NPI: 1801209051
Provider Name (Legal Business Name): GULF STATES HEALTH PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7855 HOWELL BLVD STE 160
BATON ROUGE LA
70807-5257
US

IV. Provider business mailing address

5710 LBJ FWY SUITE 325
DALLAS TX
75240-6324
US

V. Phone/Fax

Practice location:
  • Phone: 855-360-1446
  • Fax: 888-489-3558
Mailing address:
  • Phone: 214-888-8099
  • Fax: 214-261-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.007095-IR
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NIZAR ALIKHAN
Title or Position: CREDENTIALING CONTACT,AO
Credential:
Phone: 215-888-8099