Provider Demographics
NPI:1518946979
Name:YOUR PHARMACY LLC
Entity Type:Organization
Organization Name:YOUR PHARMACY LLC
Other - Org Name:YOUR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MGT
Authorized Official - Phone:859-234-5400
Mailing Address - Street 1:208 W PLEASANT ST
Mailing Address - Street 2:STE 2
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-2421
Mailing Address - Country:US
Mailing Address - Phone:859-234-5400
Mailing Address - Fax:859-234-5399
Practice Address - Street 1:208 W PLEASANT ST
Practice Address - Street 2:STE 2
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-2421
Practice Address - Country:US
Practice Address - Phone:859-234-5400
Practice Address - Fax:859-234-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP069523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54000294Medicaid
1826277OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY54000294Medicaid