Provider Demographics
NPI:1356507180
Name:PENDLETON PHARMACIST GROUP INC
Entity Type:Organization
Organization Name:PENDLETON PHARMACIST GROUP INC
Other - Org Name:TOTAL CARE PHARMACY #5
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-654-3232
Mailing Address - Street 1:209 S MAIN CROSS ST
Mailing Address - Street 2:
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041-1203
Mailing Address - Country:US
Mailing Address - Phone:606-845-2101
Mailing Address - Fax:606-849-2633
Practice Address - Street 1:1100 W SHELBY ST
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:KY
Practice Address - Zip Code:41040-1046
Practice Address - Country:US
Practice Address - Phone:859-654-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100056430Medicaid
KY1823752OtherNCPDP
KY6527000001Medicare NSC