Provider Demographics
NPI:1073627055
Name:C D S 10 PHARMACY LLC
Entity Type:Organization
Organization Name:C D S 10 PHARMACY LLC
Other - Org Name:CDS #10 PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-781-5661
Mailing Address - Street 1:1308 ASHLEY CIR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3339
Mailing Address - Country:US
Mailing Address - Phone:270-781-5661
Mailing Address - Fax:270-781-5652
Practice Address - Street 1:1308 ASHLEY CIR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3339
Practice Address - Country:US
Practice Address - Phone:270-781-5661
Practice Address - Fax:270-781-5652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP009723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2029251OtherPK
KY7100179220Medicaid
5667520001Medicare NSC