Provider Demographics
NPI:1407589427
Name:GREAT RIVER PHARMACY LLC
Entity Type:Organization
Organization Name:GREAT RIVER PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGSDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:270-564-4612
Mailing Address - Street 1:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:KY
Mailing Address - Zip Code:42087-0448
Mailing Address - Country:US
Mailing Address - Phone:270-564-4612
Mailing Address - Fax:
Practice Address - Street 1:2009 S 7TH ST
Practice Address - Street 2:
Practice Address - City:HICKMAN
Practice Address - State:KY
Practice Address - Zip Code:42050-1841
Practice Address - Country:US
Practice Address - Phone:270-236-2588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy