Provider Demographics
NPI:1083069728
Name:APOTHECARE PHARMACY OF ELIZABETHTOWN P S C
Entity Type:Organization
Organization Name:APOTHECARE PHARMACY OF ELIZABETHTOWN P S C
Other - Org Name:APOTHECARE PHARMACY OF ELIZABETHTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-739-0303
Mailing Address - Street 1:1239 WOODLAND DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2770
Mailing Address - Country:US
Mailing Address - Phone:270-739-0303
Mailing Address - Fax:270-234-0101
Practice Address - Street 1:1239 WOODLAND DR STE 102
Practice Address - Street 2:SUITE 102
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2770
Practice Address - Country:US
Practice Address - Phone:270-739-0303
Practice Address - Fax:270-234-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP063203336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159809OtherPK
KY54033097Medicaid
KY90270471Medicaid
1214020001Medicare NSC