Healthcare Provider Details

I. General information

NPI: 1346071461
Provider Name (Legal Business Name): FTW LAKE CHARLES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W MCNEESE ST
LAKE CHARLES LA
70605-4241
US

IV. Provider business mailing address

1505 W MCNEESE ST
LAKE CHARLES LA
70605-4241
US

V. Phone/Fax

Practice location:
  • Phone: 337-477-7733
  • Fax: 337-477-6996
Mailing address:
  • Phone: 337-477-7733
  • Fax: 337-477-6996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GLYNDA FUSELIER
Title or Position: MANAGING MEMBER
Credential: PHARMD
Phone: 318-715-0015