Provider Demographics
NPI:1306088240
Name:GRANT COUNTY DRUGS-NORTH
Entity type:Organization
Organization Name:GRANT COUNTY DRUGS-NORTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD,RPH
Authorized Official - Phone:859-823-5271
Mailing Address - Street 1:24 S MAIN ST
Mailing Address - Street 2:P.O. BOX 106
Mailing Address - City:DRY RIDGE
Mailing Address - State:KY
Mailing Address - Zip Code:41035-7329
Mailing Address - Country:US
Mailing Address - Phone:859-823-5271
Mailing Address - Fax:859-428-0595
Practice Address - Street 1:375 VIOLET RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8535
Practice Address - Country:US
Practice Address - Phone:859-428-3784
Practice Address - Fax:859-428-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP073343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS7100068010Medicaid