Provider Demographics
NPI:1740397876
Name:CLAY DRUG STORE INC
Entity Type:Organization
Organization Name:CLAY DRUG STORE INC
Other - Org Name:CLAY DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-664-2270
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:KY
Mailing Address - Zip Code:42404-0008
Mailing Address - Country:US
Mailing Address - Phone:270-664-2270
Mailing Address - Fax:270-664-6633
Practice Address - Street 1:9055 ST RT 132 W
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:KY
Practice Address - Zip Code:42404
Practice Address - Country:US
Practice Address - Phone:270-664-2270
Practice Address - Fax:270-664-6633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
KYP064923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123849OtherPK
KY7100112330Medicaid
0677170001Medicare NSC