Healthcare Provider Details

I. General information

NPI: 1528141157
Provider Name (Legal Business Name): MABILES CORNER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GULF ST
COUSHATTA LA
71019-9014
US

IV. Provider business mailing address

PO BOX 609
COUSHATTA LA
71019-0609
US

V. Phone/Fax

Practice location:
  • Phone: 318-932-5727
  • Fax: 318-932-5630
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY-004694-IR
License Number StateLA

VIII. Authorized Official

Name: CONNIE MABILE
Title or Position: PRES
Credential:
Phone: 318-932-5727