Provider Demographics
NPI:1033750187
Name:BOURBONTOWN PHARMACY LLC
Entity Type:Organization
Organization Name:BOURBONTOWN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-370-4336
Mailing Address - Street 1:1002 S BROADWAY ST STE 7
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1822 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:KY
Practice Address - Zip Code:40361-1109
Practice Address - Country:US
Practice Address - Phone:859-900-0991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy