Healthcare Provider Details

I. General information

NPI: 1114031192
Provider Name (Legal Business Name): ROSEPINE FAMILY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18507 CENTRAL AVE
ROSEPINE LA
70659
US

IV. Provider business mailing address

PO BOX 408
ROSEPINE LA
70659-0408
US

V. Phone/Fax

Practice location:
  • Phone: 337-462-0177
  • Fax: 337-462-0078
Mailing address:
  • Phone: 337-462-0177
  • Fax: 337-462-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.002000-IR
License Number StateLA

VIII. Authorized Official

Name: MATTHEW PETERSON
Title or Position: OWNER
Credential:
Phone: 337-462-0177