Provider Demographics
NPI:1437158730
Name:BLUEGRASS PHARMACIES, INC
Entity Type:Organization
Organization Name:BLUEGRASS PHARMACIES, INC
Other - Org Name:BLUEGRASS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-825-2775
Mailing Address - Street 1:1128 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1265
Mailing Address - Country:US
Mailing Address - Phone:270-825-2775
Mailing Address - Fax:270-825-0413
Practice Address - Street 1:1128 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1265
Practice Address - Country:US
Practice Address - Phone:270-825-2775
Practice Address - Fax:270-825-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO1392332B00000X, 3336H0001X
KY1392333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54016753Medicaid
KY54016753Medicaid