Provider Demographics
NPI:1376767129
Name:CHILDERS, CHARLES PATRICK (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PATRICK
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 THOROUGHBRED LN
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:KY
Mailing Address - Zip Code:41094-8143
Mailing Address - Country:US
Mailing Address - Phone:859-363-8388
Mailing Address - Fax:
Practice Address - Street 1:20 FERGUSON BLVD
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035-8635
Practice Address - Country:US
Practice Address - Phone:859-824-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist