Healthcare Provider Details

I. General information

NPI: 1043838469
Provider Name (Legal Business Name): VIDRINE PHARMACEUTICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E PRIEN LAKE RD
LAKE CHARLES LA
70601-8507
US

IV. Provider business mailing address

404 E PRIEN LAKE RD
LAKE CHARLES LA
70601-8507
US

V. Phone/Fax

Practice location:
  • Phone: 337-436-7216
  • Fax:
Mailing address:
  • Phone: 337-436-7216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. JESSE VIDRINE
Title or Position: OWNER
Credential:
Phone: 337-436-7216