Provider Demographics
NPI:1306943147
Name:AUDUBON PHARMACY INC
Entity type:Organization
Organization Name:AUDUBON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLOM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:502-371-1002
Mailing Address - Street 1:3503 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1009
Mailing Address - Country:US
Mailing Address - Phone:502-371-1002
Mailing Address - Fax:502-371-1005
Practice Address - Street 1:3503 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1009
Practice Address - Country:US
Practice Address - Phone:502-371-1002
Practice Address - Fax:502-371-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP070583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2034337OtherPK
KY54011911Medicaid
5602310001Medicare NSC