Provider Demographics
NPI:1295020741
Name:ETOWN PHARMACY LLC
Entity Type:Organization
Organization Name:ETOWN PHARMACY LLC
Other - Org Name:ETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAJIUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-686-6420
Mailing Address - Street 1:914 N DIXIE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2536
Mailing Address - Country:US
Mailing Address - Phone:270-900-1583
Mailing Address - Fax:270-900-1594
Practice Address - Street 1:914 N DIXIE AVE STE 103
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2536
Practice Address - Country:US
Practice Address - Phone:270-900-1583
Practice Address - Fax:270-900-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP074513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100170610Medicaid
2130699OtherPK
KY6629090001Medicare NSC