Provider Demographics
NPI:1568402212
Name:BRANDENBURG PHARMACY CARE LLC
Entity Type:Organization
Organization Name:BRANDENBURG PHARMACY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODBY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-422-2422
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-0455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 BYPASS RD STE D
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1745
Practice Address - Country:US
Practice Address - Phone:270-422-2422
Practice Address - Fax:270-422-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP065563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1826342OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KY54000799Medicaid
1826342OtherOTHER ID NUMBER
1826342OtherOTHER ID NUMBER-COMMERCIAL NUMBER