Provider Demographics
NPI:1407152515
Name:EASTRIDGE-PHELPS PHARMACY LLC
Entity Type:Organization
Organization Name:EASTRIDGE-PHELPS PHARMACY LLC
Other - Org Name:EASTRIDGE-PHELPS PHARMACY GREENSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-299-2333
Mailing Address - Street 1:460 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42743-1402
Mailing Address - Country:US
Mailing Address - Phone:270-299-2333
Mailing Address - Fax:270-299-2334
Practice Address - Street 1:460 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1402
Practice Address - Country:US
Practice Address - Phone:270-299-2333
Practice Address - Fax:270-299-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP074393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128693OtherPK
KY7100149910Medicaid
2128693OtherPK