Provider Demographics
NPI:1558466839
Name:INEZ DRUG STORE INC
Entity Type:Organization
Organization Name:INEZ DRUG STORE INC
Other - Org Name:INEZ DRUG STORE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON-GALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-298-3800
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-0381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 OLD MIDDLE FRK
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224
Practice Address - Country:US
Practice Address - Phone:606-298-3800
Practice Address - Fax:606-298-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP005173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2028795OtherPK
KY54010053Medicaid
2028795OtherPK