Provider Demographics
NPI:1669403697
Name:HEALTH MART OF JENNINGS LLC
Entity type:Organization
Organization Name:HEALTH MART OF JENNINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-616-9500
Mailing Address - Street 1:818 N CUSHING AVE
Mailing Address - Street 2:
Mailing Address - City:KAPLAN
Mailing Address - State:LA
Mailing Address - Zip Code:70548-2615
Mailing Address - Country:US
Mailing Address - Phone:337-643-7952
Mailing Address - Fax:337-643-7953
Practice Address - Street 1:1322 ELTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4100
Practice Address - Country:US
Practice Address - Phone:337-616-9500
Practice Address - Fax:337-616-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X, 3336L0003X, 3336L0003X
LAPHY.005639-IR3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1233994Medicaid
2035363OtherPK
LA1233994Medicaid