Provider Demographics
NPI:1326005166
Name:PACK MEDICAL INC.
Entity Type:Organization
Organization Name:PACK MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:VANOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-920-9701
Mailing Address - Street 1:PO BOX 2203
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2203
Mailing Address - Country:US
Mailing Address - Phone:606-920-9701
Mailing Address - Fax:606-920-9716
Practice Address - Street 1:1653 GREENUP AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7615
Practice Address - Country:US
Practice Address - Phone:606-920-9701
Practice Address - Fax:606-920-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6264014000Medicaid
KY000000070191OtherBCBS PROVIDER
KY90060104Medicaid
OH0183037Medicaid
WV6264014000Medicaid
OH0324600001Medicare ID - Type UnspecifiedPROVIDER
WV0324600001Medicare ID - Type UnspecifiedPROVIDER
KY=========OtherCOMMERCIAL