Provider Demographics
NPI:1003921032
Name:MARSHALL COUNTY HOSP DISTRICT
Entity Type:Organization
Organization Name:MARSHALL COUNTY HOSP DISTRICT
Other - Org Name:MARSHALL COUNTY HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-527-4800
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-0630
Mailing Address - Country:US
Mailing Address - Phone:270-527-4800
Mailing Address - Fax:270-527-4893
Practice Address - Street 1:615 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5042
Practice Address - Country:US
Practice Address - Phone:270-527-4885
Practice Address - Fax:270-527-4893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
KYP051093336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2030096OtherPK
KY54025473Medicaid
KY54025473Medicaid