Provider Demographics
NPI:1366402364
Name:PINE PRAIRIE PHARMACY,INC
Entity type:Organization
Organization Name:PINE PRAIRIE PHARMACY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:BART
Authorized Official - Middle Name:
Authorized Official - Last Name:ENICKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-599-2050
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:PINE PRAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70576-0800
Mailing Address - Country:US
Mailing Address - Phone:337-599-2050
Mailing Address - Fax:337-599-2596
Practice Address - Street 1:10711 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:PINE PRAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70576
Practice Address - Country:US
Practice Address - Phone:337-599-2050
Practice Address - Fax:337-599-2596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336L0003X
LA5075-IR183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1270733Medicaid
LA5057800001Medicare ID - Type Unspecified