Provider Demographics
NPI:1942799309
Name:LEWIS COUNTY PRIMARY CARE CENTER INC
Entity Type:Organization
Organization Name:LEWIS COUNTY PRIMARY CARE CENTER INC
Other - Org Name:BRACKEN COUNTY FAMILY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY AND ANCILLARY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-956-0188
Mailing Address - Street 1:211 KY 59
Mailing Address - Street 2:P.O. BOX 550
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-7647
Mailing Address - Country:US
Mailing Address - Phone:606-956-0188
Mailing Address - Fax:
Practice Address - Street 1:1551 AUGUSTA CHATHAM RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KY
Practice Address - Zip Code:41002-9224
Practice Address - Country:US
Practice Address - Phone:606-956-0188
Practice Address - Fax:606-796-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP079993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177434OtherPK