Provider Demographics
NPI:1194109082
Name:CARROLL, JUSTIN BRYCE
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BRYCE
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2284 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1604
Mailing Address - Country:US
Mailing Address - Phone:859-278-3471
Mailing Address - Fax:
Practice Address - Street 1:2284 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1604
Practice Address - Country:US
Practice Address - Phone:859-278-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist