Provider Demographics
NPI:1598708836
Name:JENNIE STUART MEDICAL CENTER
Entity Type:Organization
Organization Name:JENNIE STUART MEDICAL CENTER
Other - Org Name:JENNIE STUART MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-887-0191
Mailing Address - Street 1:1724 KENTON ST
Mailing Address - Street 2:STE 1E
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1981
Mailing Address - Country:US
Mailing Address - Phone:270-887-0191
Mailing Address - Fax:270-887-0201
Practice Address - Street 1:320 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1965
Practice Address - Country:US
Practice Address - Phone:270-887-0191
Practice Address - Fax:270-887-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP050343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54013263Medicaid
2029276OtherPK