Healthcare Provider Details

I. General information

NPI: 1366402364
Provider Name (Legal Business Name): PINE PRAIRIE PHARMACY,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10711 VETERANS MEMORIAL HWY
PINE PRAIRIE LA
70576
US

IV. Provider business mailing address

PO BOX 800
PINE PRAIRIE LA
70576-0800
US

V. Phone/Fax

Practice location:
  • Phone: 337-599-2050
  • Fax: 337-599-2596
Mailing address:
  • Phone: 337-599-2050
  • Fax: 337-599-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5075-IR
License Number StateLA

VIII. Authorized Official

Name: MR. BART ENICKE
Title or Position: PRESIDENT/PHARMACIST-IN-CHARGE
Credential: RPH
Phone: 337-599-2050