Healthcare Provider Details

I. General information

NPI: 1932207081
Provider Name (Legal Business Name): URBAN DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 JACKSON ST
MONROE LA
71202-2532
US

IV. Provider business mailing address

1910 JACKSON ST
MONROE LA
71202-2532
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-1374
  • Fax: 318-398-0888
Mailing address:
  • Phone: 318-388-1374
  • Fax: 318-398-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2328IR
License Number StateLA

VIII. Authorized Official

Name: DR. KERMIT LAMAR WALTERS JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 318-388-1374