Healthcare Provider Details

I. General information

NPI: 1760971840
Provider Name (Legal Business Name): MONTECINO DRUGS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5917 LAPALCO BLVD
MARRERO LA
70072-4833
US

IV. Provider business mailing address

5917 LAPALCO BLVD
MARRERO LA
70072-4833
US

V. Phone/Fax

Practice location:
  • Phone: 204-343-4822
  • Fax: 504-340-3090
Mailing address:
  • Phone: 204-343-4822
  • Fax: 504-340-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY.007687-IR
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS MONTECINO
Title or Position: PRESIDENT/PHARMACY MANAGRER
Credential:
Phone: 504-347-0085