Provider Demographics
NPI:1841486156
Name:PROFESSIONAL PHARMACY OF SOMERSET LLC
Entity type:Organization
Organization Name:PROFESSIONAL PHARMACY OF SOMERSET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DAULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-1169
Mailing Address - Street 1:342 BOGLE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2851
Mailing Address - Country:US
Mailing Address - Phone:606-679-1169
Mailing Address - Fax:606-679-1049
Practice Address - Street 1:342 BOGLE ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2851
Practice Address - Country:US
Practice Address - Phone:606-679-1169
Practice Address - Fax:606-679-1049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7100039650332B00000X
KYP072063336C0003X
KYP078493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035126OtherPK
6014030001Medicare NSC