Provider Demographics
NPI:1134448863
Name:GLASS ENTERPRISES LLC
Entity type:Organization
Organization Name:GLASS ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/LLC MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-619-0815
Mailing Address - Street 1:PO BOX 4344
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:KY
Mailing Address - Zip Code:40347-4344
Mailing Address - Country:US
Mailing Address - Phone:859-846-9640
Mailing Address - Fax:859-846-9640
Practice Address - Street 1:115 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:KY
Practice Address - Zip Code:40347-5024
Practice Address - Country:US
Practice Address - Phone:859-846-4146
Practice Address - Fax:859-846-4148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
KYP073993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125110OtherPK
KY6472360001Medicare NSC