Provider Demographics
NPI:1720537251
Name:PLAZA DRUG OF LONDON LLC
Entity Type:Organization
Organization Name:PLAZA DRUG OF LONDON LLC
Other - Org Name:PLAZA DRUG OF LONDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIZEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-657-5245
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40755-0202
Mailing Address - Country:US
Mailing Address - Phone:606-657-5245
Mailing Address - Fax:606-657-5382
Practice Address - Street 1:731 N LAUREL RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-6025
Practice Address - Country:US
Practice Address - Phone:606-657-5245
Practice Address - Fax:606-657-5382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP076553336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100430090Medicaid
2164322OtherPK
KY7100281580Medicaid
KY7100430090Medicaid