PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC

Provider Demographics

• NPI: 1255376620
• Name: PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC
• Entity type: Organization
• Organization Name: PHARMACOGENETICS DIAGNOSTIC LABORATORY LLC
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: VP
• Authorized Official - First Name: MARK
• Authorized Official - Last Name: LINDER
• Authorized Official - Credentials: PHD
• Authorized Official - Phone: 502-569-1584
• Mailing Address - Street 1: 201 E JEFFERSON ST
• Mailing Address - Street 2: SUITE 309
• Mailing Address - City: LOUISVILLE
• Mailing Address - State: KY
• Mailing Address - Zip Code: 40202-1246
• Mailing Address - Country: US
• Mailing Address - Phone: 502-569-1584
• Mailing Address - Fax: 502-569-1054
• Practice Address - Street 1: 201 E JEFFERSON ST
• Practice Address - Street 2: SUITE 309
• Practice Address - City: LOUISVILLE
• Practice Address - State: KY
• Practice Address - Zip Code: 40202-1246
• Practice Address - Country: US
• Practice Address - Phone: 502-569-1584
• Practice Address - Fax: 502-569-1585
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-18
• Last Update Date: 2015-05-07

Provider Licenses

State	License ID	Taxonomies
KY	200251	291U00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	291U00000X	Laboratories	Clinical Medical Laboratory

Provider Identifiers

State	Identifier ID	ID Type	Issuer
PA	102795040 0001	Medicaid
ME	1255376620	Medicaid
MI	2659764	Medicaid
OH	0065657	Medicaid
IA	0110438	Medicaid
NE	100262578-00	Medicaid
MO	1255376620	Medicaid
OR	500652629	Medicaid
WA	1255376620	Medicaid
KS	200970280A	Medicaid
MS	00026220	Medicaid
AR	195993709	Medicaid
LA	2338391	Medicaid
CO	50121715	Medicaid
NC	7001484	Medicaid
NJ	0380351	Medicaid
AL	1255376620	Medicaid
MT	1255376620	Medicaid
UT	1255376620	Medicaid
TN	1530585	Medicaid
IN	201093810A	Medicaid
KY	7405899	Medicaid
AZ	808295	Medicaid
GA	003132163A	Medicaid
ID	1255376620	Medicaid
MD	4215397 00	Medicaid
KY	000000531561	Other	ANTHEM BLUE CROSS
NM	06555519	Medicaid
VA	1255376620	Medicaid
WV	3810025173	Medicaid
AK	1582673	Medicaid
HI	738908	Medicaid
SC	L00368	Medicaid
IL	TIN-001	Medicaid
AR	195993709	Medicaid