Provider Demographics
NPI:1386019099
Name:CROFTON PHARMACY, LLC
Entity Type:Organization
Organization Name:CROFTON PHARMACY, LLC
Other - Org Name:CROFTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-775-2771
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-0126
Mailing Address - Country:US
Mailing Address - Phone:270-424-8965
Mailing Address - Fax:
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:KY
Practice Address - Zip Code:42217-8288
Practice Address - Country:US
Practice Address - Phone:270-424-8965
Practice Address - Fax:270-424-8965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07729333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155592OtherPK
KY54017355Medicaid