Healthcare Provider Details

I. General information

NPI: 1023191103
Provider Name (Legal Business Name): OUR LADY OF GUADALUPE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 HIGHWAY 363
WASHINGTON LA
70589-4141
US

IV. Provider business mailing address

904 HIGHWAY 363
WASHINGTON LA
70589-4141
US

V. Phone/Fax

Practice location:
  • Phone: 337-826-9810
  • Fax: 337-826-9813
Mailing address:
  • Phone: 337-826-9810
  • Fax: 337-826-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY005564IR
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN LEE
Title or Position: OWNER
Credential: OWNER
Phone: 337-826-9810