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General NPI Number Information
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NPI Number | 1639619653
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Entity Type | Organization
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Legal Business Name | LIL BOOS CORNER STORE LLC
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Dates
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Enumeration Date | 02/24/2017
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Last Update Date | 07/18/2023
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Provider Practice Location Address
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Address Line | 415 ST. CLAIR RD. STE. C
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City | BOYCE
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State | LA
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Zip | 71409
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Country | US
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Telephone | 318-793-2028
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Fax | 859-594-6639
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Provider Business Mailing Address
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Address Line | 415 ST. CLAIR ROAD; SUITE C
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City | BOYCE
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State | LA
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Zip | 71409
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Country | US
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Telephone | 318-793-2028
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Fax | 859-594-6639
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT MADDOX IV
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Credential |
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Telephone | 318-793-2028
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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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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHY.007439-IR
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License Number State | LA
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