=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366402364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINE PRAIRIE PHARMACY,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2006
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10711 VETERANS MEMORIAL HWY
-----------------------------------------------------
City | PINE PRAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-599-2050
-----------------------------------------------------
Fax | 337-599-2596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 800
-----------------------------------------------------
City | PINE PRAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70576-0800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-599-2050
-----------------------------------------------------
Fax | 337-599-2596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PHARMACIST-IN-CHARGE
-----------------------------------------------------
Name | MR. BART ENICKE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 337-599-2050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5075-IR
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------