Provider Demographics
NPI:1235688920
Name:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Entity Type:Organization
Organization Name:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Other - Org Name:SOUTH SHORE FAMILY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:606-956-0188
Mailing Address - Street 1:142 DEPOT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-9306
Mailing Address - Country:US
Mailing Address - Phone:606-932-2138
Mailing Address - Fax:606-932-2120
Practice Address - Street 1:142 DEPOT DR
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-9306
Practice Address - Country:US
Practice Address - Phone:606-932-2138
Practice Address - Fax:606-932-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP077913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100442910Medicaid
2164227OtherPK
OH0189046Medicaid