MEDICARE: PRAIRIEVILLE PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PHY006653IR	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2138799	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063751964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIEVILLE PHARMACY LLC

Provider Business Mailing Address
First Line	:	16270 AIRLINE HWY
Second Line	:	STE A-100
City	:	PRAIRIEVILLE
State	:	LA
Zip	:	70769-4589
Country	:	US
Telephone Number	:	225-677-7979
Fax Number	:	225-677-7990

Provider Business Practice Location Address
First Line	:	16270 AIRLINE HWY
Second Line	:	STE A-100
City	:	PRAIRIEVILLE
State	:	LA
Zip	:	70769-4589
Country	:	US
Telephone Number	:	225-677-7979
Fax Number	:	225-677-7990

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MARC SCHEXNAILDER
Credential	:
Telephone Number	:	225-677-7979

Provider Enumeration Date	:	02/12/2013
Last Update Date	:	11/22/2016

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