=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073402665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY 1920 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2025
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 E MADISON AVE
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71220-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-281-2305
-----------------------------------------------------
Fax | 318-283-2033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 860
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71221-0860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-880-7622
-----------------------------------------------------
Fax | 318-283-2033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RAKTIM R BARUAH
-----------------------------------------------------
Credential | N/A
-----------------------------------------------------
Telephone | 318-880-7622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------