Provider Demographics
NPI:1093713463
Name:ELY DRUGS INC
Entity Type:Organization
Organization Name:ELY DRUGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:HUDNALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD BCPS
Authorized Official - Phone:270-651-8359
Mailing Address - Street 1:P.O. BOX 1778
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1778
Mailing Address - Country:US
Mailing Address - Phone:270-651-8359
Mailing Address - Fax:270-651-5741
Practice Address - Street 1:415 HAPPY VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141
Practice Address - Country:US
Practice Address - Phone:270-651-8359
Practice Address - Fax:270-651-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BP3500X
KYP07216332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000069929OtherDME
KY69929OtherDME
KY90150053Medicaid
KY000000069929OtherDME