Healthcare Provider Details

I. General information

NPI: 1063481752
Provider Name (Legal Business Name): ISLAND PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 CHISUM ST
SICILY ISLAND LA
71368-4807
US

IV. Provider business mailing address

311 CHISUM ST
SICILY ISLAND LA
71368-4807
US

V. Phone/Fax

Practice location:
  • Phone: 318-389-5807
  • Fax: 318-389-5842
Mailing address:
  • Phone: 318-389-5807
  • Fax: 318-389-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number507-IR
License Number StateLA

VIII. Authorized Official

Name: A G BIRD
Title or Position: OWNER
Credential: PHARMACIST
Phone: 318-389-5807