Organization
IDEAL HEALTH MART PHARMACY INC
Active
Other names
ideal health mart
Organization subpart
No
Provider details
NPI number
Authorized official
KESA LANE (RPH/OWNER)
(337) 463-7210
Entity
Organization
Contact information
Practice address
610 N PINE ST, DERIDDER, LA 70634-3546
(337) 463-7210
(337) 462-0930
Mailing address
610 N PINE ST, DERIDDER, LA 70634-3546
(337) 463-7210
(337) 462-0930
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
006477
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1902801
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
2201344
—
LA
Enumeration date
01/08/2007
Last updated
05/16/2014
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