Provider Demographics
NPI:1851432702
Name:FALLS ROAD PHARMACY INC
Entity Type:Organization
Organization Name:FALLS ROAD PHARMACY INC
Other - Org Name:FALLS ROAD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PIC
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-258-0000
Mailing Address - Street 1:40 MOONBOW PLZ
Mailing Address - Street 2:STE 1
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-8982
Mailing Address - Country:US
Mailing Address - Phone:606-258-0000
Mailing Address - Fax:606-258-0002
Practice Address - Street 1:40 MOONBOW PLZ
Practice Address - Street 2:STE 1
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8982
Practice Address - Country:US
Practice Address - Phone:606-258-0000
Practice Address - Fax:606-258-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP068313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54004437Medicaid
1827700OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY54004437Medicaid