Provider Demographics
NPI:1407367410
Name:ST MATTHEWS SPECIALTY PHARMACY LLC
Entity Type:Organization
Organization Name:ST MATTHEWS SPECIALTY PHARMACY LLC
Other - Org Name:ST MATTHEWS SPECIALTY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-314-0146
Mailing Address - Street 1:9500 ORMSBY STATION RD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4076
Mailing Address - Country:US
Mailing Address - Phone:502-205-1729
Mailing Address - Fax:844-524-4673
Practice Address - Street 1:200 N HURSTBOURNE PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5138
Practice Address - Country:US
Practice Address - Phone:844-690-4462
Practice Address - Fax:844-524-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
KYP078693336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175327OtherPK