Healthcare Provider Details

I. General information

NPI: 1669712154
Provider Name (Legal Business Name): INNIS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6430 LA HWY 1
INNIS LA
70747
US

IV. Provider business mailing address

6430 LA HWY 1
BATCHELOR LA
70715
US

V. Phone/Fax

Practice location:
  • Phone: 225-202-8424
  • Fax:
Mailing address:
  • Phone: 225-202-8424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14114
License Number StateLA

VIII. Authorized Official

Name: MR. MERLIN ANTHONY LACOMBE JR.
Title or Position: PIC/OWNER
Credential: P,D.
Phone: 225-202-8424