| Organization Name: | MALL PHARMACY LLC |
| NPI Number: | 1417341413 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MATTHEW RYAN OGLEE (PHARMACIST/ OWNER) |
| Mailing Address: | 531 S Main St Springhill |
| State: | LA US |
| Postal Code: | 710754027 |
| Phone Number: | 3185393622 |
| Fax Number: | 3185395189 |
| NPI Enumeration Date: | 03/27/2015 |
| NPI Last Update Date: | 03/27/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336C0004X |
| License Number: | PHY.007009-IR |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | LA |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | Compounding Pharmacy |
| Taxonomy Definition: | A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner |