Healthcare Provider Details

I. General information

NPI: 1538180500
Provider Name (Legal Business Name): PORT ALLEN SUPERMARKET INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N ALEXANDER AVE
PORT ALLEN LA
70767-2514
US

IV. Provider business mailing address

220 N ALEXANDER AVE
PORT ALLEN LA
70767-2514
US

V. Phone/Fax

Practice location:
  • Phone: 225-343-7855
  • Fax: 225-344-4197
Mailing address:
  • Phone: 225-343-7855
  • Fax: 225-344-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number003541IR
License Number StateLA

VIII. Authorized Official

Name: RONALD INKROTT
Title or Position: PHARMACIST
Credential: RPH
Phone: 225-343-7855