Provider Demographics
NPI:1023444809
Name:HEALTH MART OF DENHAM SPRINGS LLC
Entity type:Organization
Organization Name:HEALTH MART OF DENHAM SPRINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:225-271-4995
Mailing Address - Street 1:818 N CUSHING AVE
Mailing Address - Street 2:
Mailing Address - City:KAPLAN
Mailing Address - State:LA
Mailing Address - Zip Code:70548-2615
Mailing Address - Country:US
Mailing Address - Phone:337-643-7952
Mailing Address - Fax:337-643-7953
Practice Address - Street 1:31839 LA HIGHWAY 16 STE A
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-1423
Practice Address - Country:US
Practice Address - Phone:225-271-4995
Practice Address - Fax:225-271-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
LA0067823336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2202341Medicaid
2142349OtherPK