Provider Demographics
NPI:1346387859
Name:ANTIS PHARMACY,INC
Entity Type:Organization
Organization Name:ANTIS PHARMACY,INC
Other - Org Name:OSMAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-796-2932
Mailing Address - Street 1:89 SECOND ST
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-5439
Mailing Address - Country:US
Mailing Address - Phone:606-796-2932
Mailing Address - Fax:606-796-2124
Practice Address - Street 1:89 SECOND ST
Practice Address - Street 2:
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-5439
Practice Address - Country:US
Practice Address - Phone:606-796-2932
Practice Address - Fax:606-796-2124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90040684332B00000X
KYP06079332BP3500X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0187766Medicaid
KY45540010OtherEPSDT- SPECIAL SERVICES
KY54030077Medicaid
KY90040684OtherMEDICAID DME
KY0994980001Medicare NSC