Provider Demographics
NPI:1790082923
Name:EAST KENTUCKY PHARMACY INC
Entity Type:Organization
Organization Name:EAST KENTUCKY PHARMACY INC
Other - Org Name:EAST KENTUCKY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PIC
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-785-3784
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:MALLIE
Mailing Address - State:KY
Mailing Address - Zip Code:41836-0013
Mailing Address - Country:US
Mailing Address - Phone:606-785-3784
Mailing Address - Fax:606-785-4510
Practice Address - Street 1:588 HIGHWAY 899
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822-8955
Practice Address - Country:US
Practice Address - Phone:606-785-3784
Practice Address - Fax:606-785-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP074413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128927OtherPK
KY7100151420Medicaid