Provider Demographics
NPI:1376648659
Name:PIKE PHARMACIST GROUP, LLC
Entity Type:Organization
Organization Name:PIKE PHARMACIST GROUP, LLC
Other - Org Name:UPPER LEVISA CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-370-4336
Mailing Address - Street 1:1002 S BROADWAY ST STE 7
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1463
Mailing Address - Country:US
Mailing Address - Phone:606-835-4991
Mailing Address - Fax:606-835-4219
Practice Address - Street 1:137 N. LEVISA RD.
Practice Address - Street 2:
Practice Address - City:MOUTHCARD
Practice Address - State:KY
Practice Address - Zip Code:41548
Practice Address - Country:US
Practice Address - Phone:606-835-4991
Practice Address - Fax:606-835-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP017883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010151333Medicaid
KY54019450Medicaid
2030542OtherPK
KY54019450Medicaid