Healthcare Provider Details

I. General information

NPI: 1902911936
Provider Name (Legal Business Name): GULFCOAST PHARMACEUTICAL SPECIALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1039 E HIGHWAY 30
GONZALES LA
70737-4757
US

IV. Provider business mailing address

PO BOX 489
GONZALES LA
70707-0489
US

V. Phone/Fax

Practice location:
  • Phone: 225-647-4182
  • Fax: 225-644-0460
Mailing address:
  • Phone: 225-647-4182
  • Fax: 225-644-0460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number005084IR
License Number StateLA

VIII. Authorized Official

Name: MYRA BLACK
Title or Position: OWNER
Credential:
Phone: 225-647-4182