Provider Demographics
NPI:1750308730
Name:BEREA DRUG CO INC
Entity Type:Organization
Organization Name:BEREA DRUG CO INC
Other - Org Name:BEREA DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-986-4521
Mailing Address - Street 1:402 RICHMOND RD N
Mailing Address - Street 2:STE A
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1133
Mailing Address - Country:US
Mailing Address - Phone:859-986-4521
Mailing Address - Fax:859-985-0839
Practice Address - Street 1:402 RICHMOND RD N
Practice Address - Street 2:STE A
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1133
Practice Address - Country:US
Practice Address - Phone:859-986-4521
Practice Address - Fax:859-985-0839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP073793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2028583OtherPK
KY54012976Medicaid
KY9010076900Medicaid
0920830001Medicare NSC