Provider Demographics
NPI:1871553453
Name:CLINIC PHARMACY OF MANGHAM LLC
Entity type:Organization
Organization Name:CLINIC PHARMACY OF MANGHAM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AO
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:318-248-3338
Mailing Address - Street 1:252 HIGHWAY 132
Mailing Address - Street 2:
Mailing Address - City:MANGHAM
Mailing Address - State:LA
Mailing Address - Zip Code:71259-5268
Mailing Address - Country:US
Mailing Address - Phone:318-248-3338
Mailing Address - Fax:318-248-3399
Practice Address - Street 1:252 HIGHWAY 132
Practice Address - Street 2:
Practice Address - City:MANGHAM
Practice Address - State:LA
Practice Address - Zip Code:71259-5268
Practice Address - Country:US
Practice Address - Phone:318-248-3338
Practice Address - Fax:318-248-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006681-IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2202081Medicaid
2035210OtherPK
5152900001Medicare NSC