| Organization Name: | IBERVILLE MEDICAL SUPPLIES STORE, LLC |
| NPI Number: | 1346576600 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LEE ANN HAGGENS (OWNER) |
| Mailing Address: | 58610 Belleview Dr Plaquemine |
| State: | LA US |
| Postal Code: | 707643900 |
| Phone Number: | 2253853155 |
| Fax Number: | 2256876311 |
| NPI Enumeration Date: | 10/21/2009 |
| NPI Last Update Date: | 10/21/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332BX2000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | LA |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | Oxygen Equipment & Supplies |
| Taxonomy Definition: | |