Provider Demographics
NPI:1205834314
Name:DSSK PHARMACEUTICALS
Entity Type:Organization
Organization Name:DSSK PHARMACEUTICALS
Other - Org Name:THE MEDICINE SHOPPE 1479
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:606-435-2020
Mailing Address - Street 1:145 CITIZENS LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1352
Mailing Address - Country:US
Mailing Address - Phone:606-435-2020
Mailing Address - Fax:606-487-8172
Practice Address - Street 1:145 CITIZENS LN
Practice Address - Street 2:SUITE A
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1352
Practice Address - Country:US
Practice Address - Phone:606-435-2020
Practice Address - Fax:606-487-8172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54032271Medicaid
KY1160600001Medicare ID - Type UnspecifiedRETAIL PHARMACY