Provider Demographics
NPI:1033172119
Name:GRIDER DRUG #1 LLC
Entity Type:Organization
Organization Name:GRIDER DRUG #1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:GRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-866-6477
Mailing Address - Street 1:539 MAIN ST
Mailing Address - Street 2:PO BOX 1328
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-4357
Mailing Address - Country:US
Mailing Address - Phone:270-866-6477
Mailing Address - Fax:270-866-5307
Practice Address - Street 1:539 MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4357
Practice Address - Country:US
Practice Address - Phone:270-866-6477
Practice Address - Fax:270-866-5307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P00682332B00000X
KYP006823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90009978Medicaid
KY54008453Medicaid
KY45002490Medicaid
KY90009978Medicaid
KY54008453Medicaid