Provider Demographics
NPI:1467593517
Name:DROSERA INC HUME PHARMACY
Entity Type:Organization
Organization Name:DROSERA INC HUME PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEETS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:502-267-7453
Mailing Address - Street 1:10216 TAYLORSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40299-3616
Mailing Address - Country:US
Mailing Address - Phone:502-267-7453
Mailing Address - Fax:502-267-7455
Practice Address - Street 1:10216 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONTOWN
Practice Address - State:KY
Practice Address - Zip Code:40299-3616
Practice Address - Country:US
Practice Address - Phone:502-267-7453
Practice Address - Fax:502-267-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP021913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54012281Medicaid
KY1801516OtherNABP
KY0247270001Medicare PIN