Healthcare Provider Details

I. General information

NPI: 1154543767
Provider Name (Legal Business Name): LALLIE KEMP MEDICAL CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52579 HIGHWAY 51 S
INDEPENDENCE LA
70443-2231
US

IV. Provider business mailing address

52579 HIGHWAY 51 S
INDEPENDENCE LA
70443-2231
US

V. Phone/Fax

Practice location:
  • Phone: 985-878-1317
  • Fax: 985-878-1548
Mailing address:
  • Phone: 985-878-1317
  • Fax: 985-878-1548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPHY004495IRX
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TODD FRICKER
Title or Position: PHARMACY DIRECTOR
Credential: RPH
Phone: 985-878-1280