Provider Demographics
NPI:1023114204
Name:CASHWAY PHARMACY OF JEANERETTE, LA. INC.
Entity type:Organization
Organization Name:CASHWAY PHARMACY OF JEANERETTE, LA. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-276-4101
Mailing Address - Street 1:1801 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEANERETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70544-3423
Mailing Address - Country:US
Mailing Address - Phone:337-276-4101
Mailing Address - Fax:337-276-9005
Practice Address - Street 1:1801 MAIN ST
Practice Address - Street 2:
Practice Address - City:JEANERETTE
Practice Address - State:LA
Practice Address - Zip Code:70544-3423
Practice Address - Country:US
Practice Address - Phone:337-276-4101
Practice Address - Fax:337-276-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAC000140-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1207624Medicaid