Provider Demographics
NPI:1467531137
Name:JERABEN INC
Entity Type:Organization
Organization Name:JERABEN INC
Other - Org Name:MILLS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-683-1571
Mailing Address - Street 1:1000 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3323
Mailing Address - Country:US
Mailing Address - Phone:270-683-1571
Mailing Address - Fax:270-926-4619
Practice Address - Street 1:1000 E 4TH ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3323
Practice Address - Country:US
Practice Address - Phone:270-683-1571
Practice Address - Fax:270-926-4619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP066393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1807669OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY54002191Medicaid
4352250001Medicare NSC