Provider Demographics
NPI:1578187209
Name:ST. ELIZABETH MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:ST. ELIZABETH MEDICAL CENTER, INC.
Other - Org Name:ST. ELIZABETH HEALTHCARE CANCER CARE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT & CHIEF OP
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-301-2117
Mailing Address - Street 1:1 MEDICAL VILLAGE DR.
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-304-4510
Mailing Address - Fax:859-301-4927
Practice Address - Street 1:1 MEDICAL VILLAGE DR.
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-304-4510
Practice Address - Fax:859-301-4927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy