Lil Boos Corner Store LLC
Organization Active NPI Community/Retail Pharmacy · Boyce, LA
NPI 1639619653 · NPPES record last updated Jul 18, 2023
Key facts
- NPI
- 1639619653
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- PHY.007439-IR (LA)
- Legal business name
- LIL BOOS CORNER STORE LLC
- Practice address
- 415 St. Clair Rd. Ste. C
Boyce, LA 71409 - Phone
- (318) 793-2028
- Fax
- (859) 594-6639
- NPI assigned
- Feb 24, 2017
- Organization subpart
- No
Authorized official
- Name
- Robert Maddox IV
- Title
- Owner
- Phone
- (318) 793-2028
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in LA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210308002431 | LA | Part B Supplier - Pharmacy | 5890101380 | Practice locations: Boyce, LA |
National Provider Directory
Locations
415 Saint Clair Rd
Ste C
Boyce, LA 71409
Phone (318) 793-2028
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | PHY.007439-IR | LA | Yes |
Addresses
Primary practice location
415 St. Clair Rd. Ste. C
Boyce, LA 71409
Mailing address
415 St. Clair Road; Suite C
Boyce, LA 71409
Phone (318) 793-2028
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2204980 | Medicaid | LA | |
| 2168053 | Other | PK |
Other names
- Lil Boos Pharmacy
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All providers in Boyce, LA · Community/Retail Pharmacy in Louisiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 18, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.