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General NPI Number Information
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NPI Number | 1619058468
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Entity Type | Organization
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Legal Business Name | LINE AVENUE PHARMACY INC
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 1822 LINE AVE
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City | SHREVEPORT
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State | LA
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Zip | 71101-4612
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Country | US
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Telephone | 318-221-5114
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Fax | 318-221-5137
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Provider Business Mailing Address
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Address Line | 1822 LINE AVE
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City | SHREVEPORT
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State | LA
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Zip | 71101-4612
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Country | US
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Telephone | 318-221-5114
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Fax | 318-221-5137
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | STEPHEN RANDALL CAUDLE
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Credential | PD
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Telephone | 318-221-5114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | LA 3999-IR
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 3336N0007X
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Taxonomy Name | Nuclear Pharmacy
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License Number | LA 4001-NU
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License Number State | LA
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