Provider Demographics
NPI:1710370580
Name:ELY SPECIAL PHARMACY INC.
Entity Type:Organization
Organization Name:ELY SPECIAL PHARMACY INC.
Other - Org Name:ELY SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDNALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-467-5225
Mailing Address - Street 1:4863C SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-7909
Mailing Address - Country:US
Mailing Address - Phone:270-467-5225
Mailing Address - Fax:
Practice Address - Street 1:4863C SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-7909
Practice Address - Country:US
Practice Address - Phone:270-467-5225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP076743336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150829OtherPK