Provider Demographics
NPI:1356532352
Name:GOFORTH PHARMACY LLC
Entity type:Organization
Organization Name:GOFORTH PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOFORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:606-305-1321
Mailing Address - Street 1:406 BOGLE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2840
Mailing Address - Country:US
Mailing Address - Phone:606-677-1062
Mailing Address - Fax:606-677-1182
Practice Address - Street 1:406 BOGLE ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-677-1062
Practice Address - Fax:606-677-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP072013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100025300Medicaid
1830288OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY7100004180Medicaid
5983970001Medicare NSC