Healthcare Provider Details

I. General information

NPI: 1538298187
Provider Name (Legal Business Name): BOUDREAUX'S NEW DRUG STORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E. PRIEN LAKE RD
LAKE CHARLES LA
70601
US

IV. Provider business mailing address

2551 GREENWOOD RD SUITE 110
SHREVEPORT LA
71103-3981
US

V. Phone/Fax

Practice location:
  • Phone: 337-436-7216
  • Fax: 337-436-7217
Mailing address:
  • Phone: 318-631-2005
  • Fax: 318-631-1883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4537-IR
License Number StateLA

VIII. Authorized Official

Name: DOUG BOUDREAUX
Title or Position: OWNER
Credential:
Phone: 318-631-2005