=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962784991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RACELANDS EXPRESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2011
-----------------------------------------------------
Last Update Date | 09/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4634 HIGHWAY 1 STE B
-----------------------------------------------------
City | RACELAND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70394-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-537-3303
-----------------------------------------------------
Fax | 985-537-3393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 JANET DR
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70094-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-296-7428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE
-----------------------------------------------------
Name | VINCENT BUI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-296-7428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY.006419-IR
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------