Provider Demographics
NPI:1033470034
Name:MARROWBONE FAMILY PHARMACY
Entity Type:Organization
Organization Name:MARROWBONE FAMILY PHARMACY
Other - Org Name:RUSSELL FORK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-754-7085
Mailing Address - Street 1:PO BOX 1036
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-1036
Mailing Address - Country:US
Mailing Address - Phone:606-794-3950
Mailing Address - Fax:606-754-3049
Practice Address - Street 1:10363 REGINA BELCHER HWY
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522
Practice Address - Country:US
Practice Address - Phone:606-794-7085
Practice Address - Fax:606-754-3049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY333600000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100232340Medicaid