Organization
WILLOW MINA
Active
Other names
WILLOW BARK PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
MINH NGUYEN (PRESIDENT)
(985) 772-4088
Entity
Organization
Contact information
Practice address
606 HIGHWAY 20, THIBODAUX, LA 70301-6255
(985) 633-2275
(985) 633-4703
Mailing address
606 HIGHWAY 20, THIBODAUX, LA 70301-6255
(985) 633-2275
(985) 633-4703
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHY.007400-IR
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2166319
PK
—
05
—
2204882
—
LA
Enumeration date
10/05/2016
Last updated
10/17/2024
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