Provider Demographics
NPI:1023191103
Name:OUR LADY OF GUADALUPE PHARMACY
Entity type:Organization
Organization Name:OUR LADY OF GUADALUPE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:337-826-9810
Mailing Address - Street 1:904 HIGHWAY 363
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70589-4141
Mailing Address - Country:US
Mailing Address - Phone:337-826-9810
Mailing Address - Fax:337-826-9813
Practice Address - Street 1:904 HIGHWAY 363
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:LA
Practice Address - Zip Code:70589-4141
Practice Address - Country:US
Practice Address - Phone:337-826-9810
Practice Address - Fax:337-826-9813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X, 3336M0002X
LAPHY005564IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035290OtherPK
LA1210790Medicaid
2035290OtherPK