Provider Demographics
NPI:1891858411
Name:BLUEGRASS LLC
Entity Type:Organization
Organization Name:BLUEGRASS LLC
Other - Org Name:BLUEGRASS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAROV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-990-7700
Mailing Address - Street 1:656 W STREET RD
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-5963
Mailing Address - Country:US
Mailing Address - Phone:215-676-7650
Mailing Address - Fax:215-676-7630
Practice Address - Street 1:656 W STREET RD
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-5963
Practice Address - Country:US
Practice Address - Phone:215-676-7650
Practice Address - Fax:215-676-8086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4816593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10186675001Medicaid
2081747OtherPK