Provider Demographics
NPI:1902911936
Name:GULFCOAST PHARMACEUTICAL SPECIALTY
Entity Type:Organization
Organization Name:GULFCOAST PHARMACEUTICAL SPECIALTY
Other - Org Name:GPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-647-4182
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70707-0489
Mailing Address - Country:US
Mailing Address - Phone:225-647-4182
Mailing Address - Fax:225-644-0460
Practice Address - Street 1:1039 E HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4757
Practice Address - Country:US
Practice Address - Phone:225-647-4182
Practice Address - Fax:225-644-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X
LA005084IR3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1929972OtherNCPDP PROVIDER IDENTIFICATION NUMBER
LA1270784Medicaid