Provider Demographics
NPI:1245478007
Name:EASTRIDGE-PHELPS PHARMACY LLC
Entity type:Organization
Organization Name:EASTRIDGE-PHELPS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PIC/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-789-0577
Mailing Address - Street 1:101 WINSTON WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-4953
Mailing Address - Country:US
Mailing Address - Phone:270-789-0577
Mailing Address - Fax:270-789-0578
Practice Address - Street 1:101 WINSTON WAY
Practice Address - Street 2:SUITE A
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-4953
Practice Address - Country:US
Practice Address - Phone:270-789-0577
Practice Address - Fax:270-789-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-31
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP073253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831038OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY7100060880Medicaid
1831038OtherNCPDP PROVIDER IDENTIFICATION NUMBER