Provider Demographics
NPI:1992041131
Name:CLAY MEDI CENTER PHARMACY LLC
Entity Type:Organization
Organization Name:CLAY MEDI CENTER PHARMACY LLC
Other - Org Name:CLAY MEDICENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-432-3621
Mailing Address - Street 1:509 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6195
Mailing Address - Country:US
Mailing Address - Phone:606-598-7933
Mailing Address - Fax:606-598-1887
Practice Address - Street 1:509 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6195
Practice Address - Country:US
Practice Address - Phone:606-598-7933
Practice Address - Fax:606-598-1887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP075413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139171OtherPK