MEDICARE: MR. JOHNNY LETLOW RPH

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	183500000X	Pharmacist	10748	AR
2	183500000X	Pharmacist	9774	LA

General Provider Information

NPI Number	:	1669877205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHNNY LETLOW RPH

Provider Business Mailing Address
First Line	:	534 WEBB HILL RD
Second Line	:
City	:	OAK RIDGE
State	:	LA
Zip	:	71264
Country	:	US
Telephone Number	:	318-512-6382
Fax Number	:

Provider Business Practice Location Address
First Line	:	534 WEBB HILL RD
Second Line	:
City	:	OAK RIDGE
State	:	LA
Zip	:	71264-3033
Country	:	US
Telephone Number	:	318-512-6382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2014
Last Update Date	:	10/24/2014

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