MEDICARE: DRS K L FOURNET B M DEMAHY & A R -

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	5065IR	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1911278	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821038571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRS K L FOURNET B M DEMAHY & A R -

Provider Business Mailing Address
First Line	:	410 N MAIN ST
Second Line	:
City	:	SAINT MARTINVILLE
State	:	LA
Zip	:	70582-4119
Country	:	US
Telephone Number	:	337-394-5049
Fax Number	:	337-394-5049

Provider Business Practice Location Address
First Line	:	410 N MAIN ST
Second Line	:
City	:	SAINT MARTINVILLE
State	:	LA
Zip	:	70582-4119
Country	:	US
Telephone Number	:	337-394-5049
Fax Number	:	337-394-5049

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	BYRON FOURNET
Credential	:
Telephone Number	:	337-394-5049

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/06/2011

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