Provider Demographics
NPI:1669650966
Name:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Entity Type:Organization
Organization Name:LEWIS COUNTY PRIMARY CARE CENTER, INC.
Other - Org Name:MAYSVILLE OB GYN FAMILY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:606-956-0188
Mailing Address - Street 1:927 KENTON STATION DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9617
Mailing Address - Country:US
Mailing Address - Phone:606-759-1189
Mailing Address - Fax:606-759-0586
Practice Address - Street 1:927 KENTON STATION DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9617
Practice Address - Country:US
Practice Address - Phone:606-759-1189
Practice Address - Fax:606-759-0586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP072333336C0003X, 3336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100029490Medicaid
2035010OtherPK
OH3027254Medicaid