Provider Demographics
NPI:1649520859
Name:WILLOW PHARMACY INC
Entity type:Organization
Organization Name:WILLOW PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-558-7943
Mailing Address - Street 1:1519 HIGHWAY 22 W
Mailing Address - Street 2:MADISONVILLE CENTER SUITE 5
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9489
Mailing Address - Country:US
Mailing Address - Phone:985-792-2391
Mailing Address - Fax:855-848-3661
Practice Address - Street 1:1519 HIGHWAY 22 W
Practice Address - Street 2:MADISONVILLE CENTER SUITE 5
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-9489
Practice Address - Country:US
Practice Address - Phone:985-792-2391
Practice Address - Fax:855-848-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY.006595-IR3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137008OtherPK