Provider Demographics
NPI:1962500934
Name:GRANT COUNTY DRUGS INC
Entity Type:Organization
Organization Name:GRANT COUNTY DRUGS INC
Other - Org Name:GRANT COUNTY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-823-5271
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-0106
Mailing Address - Country:US
Mailing Address - Phone:859-823-5271
Mailing Address - Fax:859-823-0039
Practice Address - Street 1:24 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035-7329
Practice Address - Country:US
Practice Address - Phone:859-823-5271
Practice Address - Fax:859-823-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
KYP068533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54008925Medicaid
KY90020413Medicaid
2027882OtherPK
KY54008925Medicaid