Provider Demographics
NPI:1376700138
Name:KIMS HOMETOWN PHARMACY INC
Entity Type:Organization
Organization Name:KIMS HOMETOWN PHARMACY INC
Other - Org Name:KIMS HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-549-7645
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-0098
Mailing Address - Country:US
Mailing Address - Phone:606-549-8700
Mailing Address - Fax:606-549-4555
Practice Address - Street 1:865 S HIGHWAY 25 W
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1918
Practice Address - Country:US
Practice Address - Phone:606-549-8700
Practice Address - Fax:606-544-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP072553336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100039220Medicaid
2035133OtherPK