Provider Demographics
NPI:1518408665
Name:PET360 PHARMACY LLC
Entity Type:Organization
Organization Name:PET360 PHARMACY LLC
Other - Org Name:PET360 PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-716-7301
Mailing Address - Street 1:2815 WATTERSON TRL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-3868
Mailing Address - Country:US
Mailing Address - Phone:502-716-7301
Mailing Address - Fax:866-253-0274
Practice Address - Street 1:2815 WATTERSON TRL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-3868
Practice Address - Country:US
Practice Address - Phone:502-716-7301
Practice Address - Fax:866-253-0274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07685333600000X
3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168106OtherPK