Provider Demographics
NPI:1639273691
Name:PDC, LLC
Entity Type:Organization
Organization Name:PDC, LLC
Other - Org Name:PRINCETON DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-365-5585
Mailing Address - Street 1:103 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445
Mailing Address - Country:US
Mailing Address - Phone:270-365-5585
Mailing Address - Fax:270-365-0559
Practice Address - Street 1:103 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-1546
Practice Address - Country:US
Practice Address - Phone:270-365-5585
Practice Address - Fax:270-365-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
KYP078583336C0003X
KYP004793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100544640Medicaid
KY7100164190Medicaid
KY7100164190Medicaid