Provider Demographics
NPI:1750370912
Name:COTTONGIM DRUG CO INC
Entity type:Organization
Organization Name:COTTONGIM DRUG CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:606-528-1304
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0570
Mailing Address - Country:US
Mailing Address - Phone:606-528-1304
Mailing Address - Fax:606-528-1305
Practice Address - Street 1:300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1458
Practice Address - Country:US
Practice Address - Phone:606-528-1304
Practice Address - Fax:606-528-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP00234333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90111188DMEMedicaid
1804132OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY54007232Medicaid
1804132OtherNCPDP PROVIDER IDENTIFICATION NUMBER