Provider Demographics
NPI:1124144456
Name:COMMONWEALTH OF KENTUCKY
Entity type:Organization
Organization Name:COMMONWEALTH OF KENTUCKY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-782-6243
Mailing Address - Street 1:2400 RUSSELLVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240
Mailing Address - Country:US
Mailing Address - Phone:270-889-6025
Mailing Address - Fax:270-889-5062
Practice Address - Street 1:2400 RUSSELLVILLE ROAD
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240
Practice Address - Country:US
Practice Address - Phone:270-889-6025
Practice Address - Fax:270-889-5062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMONWEALTH OF KENTUCKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-21
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP050103336L0003X
KYP065613336L0003X
KY1835P1300X, 1835G0303X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatricGroup - Single Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54025598Medicaid
KY5402559800Medicaid