Provider Demographics
NPI:1275548802
Name:TOMBERT INC
Entity Type:Organization
Organization Name:TOMBERT INC
Other - Org Name:TOMS FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DETRAZ
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:270-885-1524
Mailing Address - Street 1:815 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1346
Mailing Address - Country:US
Mailing Address - Phone:270-885-1524
Mailing Address - Fax:270-885-5022
Practice Address - Street 1:815 COUNTRY CLUB LN
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1346
Practice Address - Country:US
Practice Address - Phone:270-885-1524
Practice Address - Fax:270-885-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP012743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2029476OtherPK
KY54015813Medicaid