Provider Demographics
NPI:1205858206
Name:BARDWELL PHARMACY
Entity Type:Organization
Organization Name:BARDWELL PHARMACY
Other - Org Name:BARDWELL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-628-5445
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:BARDWELL
Mailing Address - State:KY
Mailing Address - Zip Code:42023-0335
Mailing Address - Country:US
Mailing Address - Phone:270-628-5445
Mailing Address - Fax:270-628-3179
Practice Address - Street 1:178 US HWY 51 N
Practice Address - Street 2:
Practice Address - City:BARDWELL
Practice Address - State:KY
Practice Address - Zip Code:42023
Practice Address - Country:US
Practice Address - Phone:270-628-5445
Practice Address - Fax:270-628-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
KYP063533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54020524Medicaid
2030630OtherPK
KY90011974Medicaid
1224150001Medicare NSC