Healthcare Provider Details

I. General information

NPI: 1548866429
Provider Name (Legal Business Name): ISLAND DRUG AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 CHISUM ST
SICILY ISLAND LA
71368-4807
US

IV. Provider business mailing address

PO BOX 729
BENTON LA
71006-0729
US

V. Phone/Fax

Practice location:
  • Phone: 318-389-5807
  • Fax: 318-389-1090
Mailing address:
  • Phone: 318-389-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN BANNISTER
Title or Position: MANAGER
Credential:
Phone: 318-927-3523