Provider Demographics
NPI:1982875514
Name:HINES PHARMACY AT WKOA LLC
Entity Type:Organization
Organization Name:HINES PHARMACY AT WKOA LLC
Other - Org Name:HINES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:270-796-1818
Mailing Address - Street 1:165 NATCHEZ TRACE AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7940
Mailing Address - Country:US
Mailing Address - Phone:270-796-1818
Mailing Address - Fax:270-796-1988
Practice Address - Street 1:165 NATCHEZ TRACE AVE
Practice Address - Street 2:STE 101
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-796-1818
Practice Address - Fax:270-796-1988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP072453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2035125OtherPK
KY7100037420Medicaid