Provider Demographics
NPI:1023193067
Name:COMMONWEALTH OF KENTUCKY
Entity Type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:HAZELWOOD CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMMISSIONER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6106
Mailing Address - Street 1:1800 BLUEGRASS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214
Mailing Address - Country:US
Mailing Address - Phone:502-361-2301
Mailing Address - Fax:
Practice Address - Street 1:1800 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214
Practice Address - Country:US
Practice Address - Phone:502-361-2301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP050113336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy