Provider Demographics
NPI:1932250842
Name:ST ELIZABETH OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:ST ELIZABETH OUTPATIENT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-301-5348
Mailing Address - Street 1:1 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3403
Mailing Address - Country:US
Mailing Address - Phone:859-301-5348
Mailing Address - Fax:859-301-5344
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-5348
Practice Address - Fax:859-301-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSPO6507282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54000591Medicaid