Provider Demographics
NPI:1104409564
Name:ADVANCE CARE PHARMACY PLLC
Entity type:Organization
Organization Name:ADVANCE CARE PHARMACY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:606-676-0199
Mailing Address - Street 1:25 MEDPARK SQUARE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-1708
Mailing Address - Country:US
Mailing Address - Phone:606-676-0199
Mailing Address - Fax:606-451-7727
Practice Address - Street 1:25 MEDPARK SQUARE DR STE 4
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1708
Practice Address - Country:US
Practice Address - Phone:606-676-0199
Practice Address - Fax:606-451-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-04
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100753830Medicaid