Provider Demographics
NPI:1710919220
Name:PADUCAH PHARMACY INC
Entity Type:Organization
Organization Name:PADUCAH PHARMACY INC
Other - Org Name:PADUCAH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-441-4390
Mailing Address - Street 1:225 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4390
Mailing Address - Fax:270-441-4393
Practice Address - Street 1:250 LONE OAK RD STE A
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4400
Practice Address - Country:US
Practice Address - Phone:270-441-4390
Practice Address - Fax:270-441-4393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP06648332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90003120Medicaid
KY1826861OtherNCPDP
KY54002308Medicaid
KY4128880001Medicare NSC