Provider Demographics
NPI:1306445259
Name:MIDDLETOWN PHARMACIST GROUP
Entity type:Organization
Organization Name:MIDDLETOWN PHARMACIST GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CRO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:502-690-2410
Mailing Address - Street 1:125 FOXGLOVE DR STE A
Mailing Address - Street 2:
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-9735
Mailing Address - Country:US
Mailing Address - Phone:502-690-2410
Mailing Address - Fax:502-690-2219
Practice Address - Street 1:11601 SHELBYVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1309
Practice Address - Country:US
Practice Address - Phone:502-690-2410
Practice Address - Fax:502-690-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-21
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100717140Medicaid