MEDICARE: PEARL RIVER RX INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PHY.006460-IR	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2133477	OTHER		PK

General Provider Information

NPI Number	:	1043582711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEARL RIVER RX INC

Provider Business Mailing Address
First Line	:	PO BOX 578
Second Line	:
City	:	RAYNE
State	:	LA
Zip	:	70578-0578
Country	:	US
Telephone Number	:	337-334-9979
Fax Number	:	337-334-9899

Provider Business Practice Location Address
First Line	:	64288 HIGHWAY 41
Second Line	:
City	:	PEARL RIVER
State	:	LA
Zip	:	70452-3602
Country	:	US
Telephone Number	:	985-863-3100
Fax Number	:	985-863-0790

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAPHAEL MECHE
Credential	:
Telephone Number	:	337-334-3399

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	01/19/2017

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Directions to “PEARL RIVER RX INC ” Practice Location

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