Provider Demographics
NPI:1710282306
Name:MCKPS LLC
Entity Type:Organization
Organization Name:MCKPS LLC
Other - Org Name:HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-214-3762
Mailing Address - Street 1:581 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-9082
Mailing Address - Country:US
Mailing Address - Phone:606-287-4719
Mailing Address - Fax:606-287-7822
Practice Address - Street 1:581 MAIN ST N
Practice Address - Street 2:
Practice Address - City:MC KEE
Practice Address - State:KY
Practice Address - Zip Code:40447-9082
Practice Address - Country:US
Practice Address - Phone:606-287-4719
Practice Address - Fax:606-287-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP074343336C0003X
KYP078093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128345OtherPK
KY6648090001Medicare NSC