Healthcare Provider Details

I. General information

NPI: 1639619653
Provider Name (Legal Business Name): LIL BOOS CORNER STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 ST. CLAIR RD. STE. C
BOYCE LA
71409
US

IV. Provider business mailing address

415 ST. CLAIR ROAD; SUITE C
BOYCE LA
71409
US

V. Phone/Fax

Practice location:
  • Phone: 318-793-2028
  • Fax: 859-594-6639
Mailing address:
  • Phone: 318-793-2028
  • Fax: 859-594-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.007439-IR
License Number StateLA

VIII. Authorized Official

Name: ROBERT MADDOX IV
Title or Position: OWNER
Credential:
Phone: 318-793-2028