Healthcare Provider Details

I. General information

NPI: 1194902122
Provider Name (Legal Business Name): PF SPAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54033 HIGHWAY 1062
LORANGER LA
70446-3538
US

IV. Provider business mailing address

PO BOX 860
LORANGER LA
70446-0860
US

V. Phone/Fax

Practice location:
  • Phone: 985-878-6622
  • Fax: 985-878-6619
Mailing address:
  • Phone: 985-878-6622
  • Fax: 985-878-6619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.005922-IR
License Number StateLA

VIII. Authorized Official

Name: AMBER TRAPEN
Title or Position: MANAGER
Credential:
Phone: 985-878-4401