=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124125679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAINCOURTVILLE PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 HWY 403
-----------------------------------------------------
City | PAINCOURTVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-369-3578
-----------------------------------------------------
Fax | 985-369-3579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 420
-----------------------------------------------------
City | PAINCOURTVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70391-0420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-369-3578
-----------------------------------------------------
Fax | 395-369-3579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID SAGONA JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-369-3578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 17136
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------