Provider Demographics
NPI:1790897890
Name:PROFESSIONAL CARE PHARMACY INC
Entity Type:Organization
Organization Name:PROFESSIONAL CARE PHARMACY INC
Other - Org Name:PROFESSIONAL CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-796-6100
Mailing Address - Street 1:207 PLUMMERS LN
Mailing Address - Street 2:STE A
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-7683
Mailing Address - Country:US
Mailing Address - Phone:606-796-6100
Mailing Address - Fax:606-796-2407
Practice Address - Street 1:207 PLUMMERS LN
Practice Address - Street 2:STE A
Practice Address - City:VANCEBURG
Practice Address - State:KY
Practice Address - Zip Code:41179-7683
Practice Address - Country:US
Practice Address - Phone:606-796-6100
Practice Address - Fax:606-796-2407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP072933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54029749Medicaid
2030633OtherPK
2030633OtherPK