Provider Demographics
NPI:1487642203
Name:LUSK, MIKE (RPH)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:
Last Name:LUSK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 436
Mailing Address - Street 2:
Mailing Address - City:BETSY LAYNE
Mailing Address - State:KY
Mailing Address - Zip Code:41605-0436
Mailing Address - Country:US
Mailing Address - Phone:606-478-9474
Mailing Address - Fax:606-478-1000
Practice Address - Street 1:111 HAYS COMPLEX
Practice Address - Street 2:HWY 23
Practice Address - City:BETSY LAYNE
Practice Address - State:KY
Practice Address - Zip Code:41605-0436
Practice Address - Country:US
Practice Address - Phone:606-478-9474
Practice Address - Fax:606-478-1000
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7768183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54017017Medicaid
KY54017017Medicaid