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General NPI Number Information
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NPI Number | 1265091474
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Entity Type | Organization
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Legal Business Name | MEDICIS LLC
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Dates
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Enumeration Date | 06/11/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 1727 IMPERIAL BLVD BLDG 4
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City | LAKE CHARLES
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State | LA
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Zip | 70605-5393
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Country | US
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Telephone | 337-540-1868
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Fax |
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Provider Business Mailing Address
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Address Line | 1727 IMPERIAL BLVD BLDG 4
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City | LAKE CHARLES
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State | LA
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Zip | 70605-5393
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Country | US
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Telephone | 337-540-1868
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Fax |
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | JAMES THIBODEAUX
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Credential |
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Telephone | 337-540-1868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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