Provider Demographics
NPI:1255354239
Name:KENTUCKY HC LLC
Entity type:Organization
Organization Name:KENTUCKY HC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNBURY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-432-2274
Mailing Address - Street 1:PO BOX 763
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-0763
Mailing Address - Country:US
Mailing Address - Phone:276-935-4777
Mailing Address - Fax:276-935-2269
Practice Address - Street 1:51 UPPER JOHNS CREEK RD
Practice Address - Street 2:
Practice Address - City:KIMPER
Practice Address - State:KY
Practice Address - Zip Code:41539
Practice Address - Country:US
Practice Address - Phone:606-631-3327
Practice Address - Fax:606-631-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP071033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1829413OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY54011564Medicaid