Provider Demographics
NPI:1669566170
Name:SALEM CLINIC PHARMACY INC
Entity type:Organization
Organization Name:SALEM CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,PIC,AO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-988-3230
Mailing Address - Street 1:PO BOX 498
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0498
Mailing Address - Country:US
Mailing Address - Phone:270-988-3230
Mailing Address - Fax:270-988-4230
Practice Address - Street 1:141 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078-8043
Practice Address - Country:US
Practice Address - Phone:270-988-3230
Practice Address - Fax:270-988-4230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP069183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54017165Medicaid
KY4554139800Medicaid
KY7100171870Medicaid
KY9001070300Medicaid
2029123OtherPK
KY54017165Medicaid