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General NPI Number Information
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NPI Number | 1982962890
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Entity Type | Organization
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Legal Business Name | JEWELLA AVENUE PHARMACY
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Dates
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Enumeration Date | 04/27/2012
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Last Update Date | 04/27/2012
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Provider Practice Location Address
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Address Line | 3610 JEWELLA AVE SUITE B
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City | SHREVEPORT
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State | LA
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Zip | 71109-4700
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Country | US
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Telephone | 318-288-3432
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Fax |
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Provider Business Mailing Address
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Address Line | 1408 CROSS LAKE CIR
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City | SHREVEPORT
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State | LA
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Zip | 71109-1935
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KAWANDA WILLIAMS
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Credential | PHARMD
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Telephone | 318-288-3432
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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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