Healthcare Provider Details

I. General information

NPI: 1972099430
Provider Name (Legal Business Name): SPRINGFIELD DRUG STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31696 HIGHWAY 22
SPRINGFIELD LA
70462-7455
US

IV. Provider business mailing address

PO BOX 10
SPRINGFIELD LA
70462-0010
US

V. Phone/Fax

Practice location:
  • Phone: 225-294-5045
  • Fax: 225-294-2142
Mailing address:
  • Phone: 225-294-5045
  • Fax: 225-294-2142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7659
License Number StateLA

VIII. Authorized Official

Name: DAVID EMILE CASANOVA
Title or Position: PHARMACIST
Credential: PD
Phone: 225-294-5045