Provider Demographics
NPI:1417040072
Name:BLUEGRASS MEDICAL SUPPLY INC TT
Entity Type:Organization
Organization Name:BLUEGRASS MEDICAL SUPPLY INC TT
Other - Org Name:THE MEDICINE SHOPPE #586
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-238-0002
Mailing Address - Street 1:900 HUSTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2137
Mailing Address - Country:US
Mailing Address - Phone:859-516-4522
Mailing Address - Fax:859-734-4370
Practice Address - Street 1:636 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-2142
Practice Address - Country:US
Practice Address - Phone:859-734-4314
Practice Address - Fax:859-734-4370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
KYP073683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100089810Medicaid
KY4590576700Medicaid
KY54024773Medicaid
2122941OtherPK
KY4590576700Medicaid
FLU0227Medicare PIN