=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164738035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMHS OUTPATIENT PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2010
-----------------------------------------------------
Last Update Date | 08/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4502 HWY 951 BUILDING 200 NORTH
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70748-0498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-634-0368
-----------------------------------------------------
Fax | 225-634-0447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 498
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70748-0498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY DIRECTOR
-----------------------------------------------------
Name | GREGORY DOLESE
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 225-634-0370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 006272
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------