Provider Demographics
NPI:1518362581
Name:CASEY COUNTY PHARMACY INC
Entity Type:Organization
Organization Name:CASEY COUNTY PHARMACY INC
Other - Org Name:CASEY COUNTY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:EUBANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-787-0119
Mailing Address - Street 1:430 N WALLACE WILKINSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-3018
Mailing Address - Country:US
Mailing Address - Phone:606-787-0119
Mailing Address - Fax:606-787-2693
Practice Address - Street 1:430 N WALLACE WILKINSON BLVD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3018
Practice Address - Country:US
Practice Address - Phone:606-787-0119
Practice Address - Fax:606-787-2693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP076583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148602OtherPK
KY7100328970Medicaid