Provider Demographics
NPI:1205077401
Name:US 25W PHARMACY INC
Entity type:Organization
Organization Name:US 25W PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-258-7024
Mailing Address - Street 1:1610 CUMBERLAND FALLS HWY
Mailing Address - Street 2:STE 9
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 CUMBERLAND FALLS HWY
Practice Address - Street 2:STE 9
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2777
Practice Address - Country:US
Practice Address - Phone:606-258-7024
Practice Address - Fax:606-258-7098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP073233336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831115OtherNCPDP PROVIDER IDENTIFICATION NUMBER