Healthcare Provider Details

I. General information

NPI: 1306901434
Provider Name (Legal Business Name): DE BLANC DRUG STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 GRAND RTE ST JOHN ST
NEW ORLEANS LA
70119
US

IV. Provider business mailing address

3111 GRAND RTE ST JOHN ST
NEW ORLEANS LA
70119
US

V. Phone/Fax

Practice location:
  • Phone: 504-949-8346
  • Fax: 504-949-5146
Mailing address:
  • Phone: 504-949-8346
  • Fax: 504-949-5146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1618IR
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT L COUSINS
Title or Position: OWNER
Credential: RPH
Phone: 504-949-8346