Healthcare Provider Details

I. General information

NPI: 1558692400
Provider Name (Legal Business Name): JOHN BIRD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 11/14/2014
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

PO BOX 38
SICILY ISLAND LA
71368-0038
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY.6199-IR
License Number StateLA

VIII. Authorized Official

Name: JOHN BIRD
Title or Position: OWNER
Credential: RPH
Phone: 318-758-5533