Provider Demographics
NPI:1376565226
Name:CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Entity Type:Organization
Organization Name:CLOVER FORK OUTPATIENT MEDICAL PROJECT INC
Other - Org Name:CLOVER FORK CLINICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRITT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:606-837-2108
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:EVARTS
Mailing Address - State:KY
Mailing Address - Zip Code:40828-0039
Mailing Address - Country:US
Mailing Address - Phone:606-837-2108
Mailing Address - Fax:606-837-9389
Practice Address - Street 1:101 CHAD ST
Practice Address - Street 2:
Practice Address - City:EVARTS
Practice Address - State:KY
Practice Address - Zip Code:40828
Practice Address - Country:US
Practice Address - Phone:606-837-2100
Practice Address - Fax:606-837-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP01273332B00000X, 332BP3500X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54034913Medicaid