Basic Information
| Provider Information | |||||||||
| NPI: | 1972722825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RX CARE OF LA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COUNTRY DRUG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5908 BRECKENRIDGE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133042221 | ||||||||
| FaxNumber: | 8882398423 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 SOUTH AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | VIVIAN | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710823209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183753784 | ||||||||
| FaxNumber: | 3183755009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIVERA | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8133042221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336C0003X | PHY6524 | LA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2201662 | 05 | LA | MEDICAID | 2135192 | 01 | PK | OTHER |