Provider Demographics
NPI:1780015461
Name:MIKE'S PHARMACY, LLC
Entity Type:Organization
Organization Name:MIKE'S PHARMACY, LLC
Other - Org Name:MIKE'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SEIBER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-871-3530
Mailing Address - Street 1:104 S. LEE TROVER TODD JR HWY
Mailing Address - Street 2:
Mailing Address - City:EARLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:42410
Mailing Address - Country:US
Mailing Address - Phone:270-905-4046
Mailing Address - Fax:270-905-4047
Practice Address - Street 1:104 S. LEE TROVER TODD JR HWY
Practice Address - Street 2:
Practice Address - City:EARLINGTON
Practice Address - State:KY
Practice Address - Zip Code:42410
Practice Address - Country:US
Practice Address - Phone:270-905-4046
Practice Address - Fax:270-905-4047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336M0002X, 3336S0011X
KYP076023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100275060Medicaid
2143183OtherPK