Provider Demographics
NPI:1942451034
Name:PENDLETON PHARMACISTS GROUP
Entity Type:Organization
Organization Name:PENDLETON PHARMACISTS GROUP
Other - Org Name:TOTAL CARE PHARMACY#5
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL RECORDS CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-845-3421
Mailing Address - Street 1:1100 W SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:KY
Mailing Address - Zip Code:41040-1046
Mailing Address - Country:US
Mailing Address - Phone:185-965-4323
Mailing Address - Fax:185-965-4327
Practice Address - Street 1:1100 W SHELBY ST
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:KY
Practice Address - Zip Code:41040-1046
Practice Address - Country:US
Practice Address - Phone:185-965-4323
Practice Address - Fax:185-965-4327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP07273332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45030739Medicaid
KY5309030001Medicare NSC