Provider Demographics
NPI:1336690122
Name:GRASSROOTS PHARMACY PLLC
Entity Type:Organization
Organization Name:GRASSROOTS PHARMACY PLLC
Other - Org Name:GRASSROOTS PHARMACY, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-227-0707
Mailing Address - Street 1:3121 ALTHORP WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2423
Mailing Address - Country:US
Mailing Address - Phone:859-227-0707
Mailing Address - Fax:859-263-1684
Practice Address - Street 1:2304 SIR BARTON WAY STE 195
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2284
Practice Address - Country:US
Practice Address - Phone:859-227-0707
Practice Address - Fax:859-263-1684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
KYP077983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2165793OtherPK