Provider Demographics
NPI:1518006048
Name:PEJ INC
Entity Type:Organization
Organization Name:PEJ INC
Other - Org Name:FAMILY PHARMACY OF JACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EVERETT
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUNAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-666-5519
Mailing Address - Street 1:265 HWY 15 S SUITE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339
Mailing Address - Country:US
Mailing Address - Phone:606-666-5519
Mailing Address - Fax:606-666-9371
Practice Address - Street 1:265 HWY 15 S SUITE 2
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-666-5519
Practice Address - Fax:606-666-9371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP065623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90001389OtherMEDICAID DME
KY54000500Medicaid
KY54000500Medicaid