=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407106578
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED RIVER PHARMACY LONG TERM CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2012
-----------------------------------------------------
Last Update Date | 10/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 MOORES LN STE A
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-4657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-792-1721
-----------------------------------------------------
Fax | 903-792-2241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1550 MOORES LN STE A
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-4657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-792-1721
-----------------------------------------------------
Fax | 903-792-2241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. DAVID BOUDREAUX
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 903-792-1721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 28137
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------