Provider Demographics
NPI:1831134030
Name:ST JOSEPH BEREA
Entity type:Organization
Organization Name:ST JOSEPH BEREA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-986-6541
Mailing Address - Street 1:305 ESTILL ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-986-6541
Practice Address - Fax:859-986-2697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO68473336C0003X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1813333OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KY54023502Medicaid
KY54023502Medicaid