Provider Demographics
NPI:1679527477
Name:MARCLO ENTERPRISES, INC
Entity type:Organization
Organization Name:MARCLO ENTERPRISES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLOESSNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PD
Authorized Official - Phone:318-992-5088
Mailing Address - Street 1:PO BOX 940
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-0940
Mailing Address - Country:US
Mailing Address - Phone:318-992-5088
Mailing Address - Fax:318-992-6446
Practice Address - Street 1:1825 EAST OAK ST
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342-0940
Practice Address - Country:US
Practice Address - Phone:318-992-5088
Practice Address - Fax:318-992-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0139-IR183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1207594Medicaid
LA1207594Medicaid