Provider Demographics
NPI:1346872397
Name:GEOGHEGAN, MALCOLM ALLEN
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:ALLEN
Last Name:GEOGHEGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 BOONE STATION RD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8673
Mailing Address - Country:US
Mailing Address - Phone:502-633-5331
Mailing Address - Fax:
Practice Address - Street 1:311 BOONE STATION RD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8673
Practice Address - Country:US
Practice Address - Phone:502-633-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0092471835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist