Provider Demographics
NPI:1518074111
Name:KAY'S HIDEAWAY PHARMACY, INC.
Entity Type:Organization
Organization Name:KAY'S HIDEAWAY PHARMACY, INC.
Other - Org Name:VITAL CARE PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:K
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-343-4663
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:504 FINKS HIDEAWAY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2470
Practice Address - Country:US
Practice Address - Phone:318-343-4663
Practice Address - Fax:318-343-4691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3929-IR3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1265870Medicaid
LA1265870Medicaid
LA=========AOtherBCBS DME
LA=========BOtherBCBS HIT
LA1265870Medicaid