Healthcare Provider Details

I. General information

NPI: 1649218728
Provider Name (Legal Business Name): NORTHEAST LA PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8860 QUIMPER PL SUITE 100
SHREVEPORT LA
71105-5686
US

IV. Provider business mailing address

8860 QUIMPER PL SUITE 100
SHREVEPORT LA
71105-5686
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-9517
  • Fax: 318-212-0057
Mailing address:
  • Phone: 318-797-9517
  • Fax: 318-212-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPHY005546IR
License Number StateLA

VIII. Authorized Official

Name: DOUGLAS ROBICHAUX
Title or Position: REGIONAL DIRECTOR OF OPERATIONS-NOR
Credential: RPH
Phone: 318-797-9517