Provider Demographics
NPI:1679610802
Name:MODERN DRUG OF BAYOU LA BATRE INC
Entity type:Organization
Organization Name:MODERN DRUG OF BAYOU LA BATRE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ACYE
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BSPH
Authorized Official - Phone:251-824-2115
Mailing Address - Street 1:13845 S WINTZELL AVE
Mailing Address - Street 2:
Mailing Address - City:BAYOU LA BATRE
Mailing Address - State:AL
Mailing Address - Zip Code:36509-2401
Mailing Address - Country:US
Mailing Address - Phone:251-824-2115
Mailing Address - Fax:251-824-4961
Practice Address - Street 1:13845 S WINTZELL AVE
Practice Address - Street 2:
Practice Address - City:BAYOU LA BATRE
Practice Address - State:AL
Practice Address - Zip Code:36509-2401
Practice Address - Country:US
Practice Address - Phone:251-824-2115
Practice Address - Fax:251-824-4961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL115113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy