Provider Demographics
NPI:1316938210
Name:DAUGHERTYS DRUG STORE INC
Entity type:Organization
Organization Name:DAUGHERTYS DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHENY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-354-2222
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:PINE KNOT
Mailing Address - State:KY
Mailing Address - Zip Code:42635-0548
Mailing Address - Country:US
Mailing Address - Phone:606-354-2222
Mailing Address - Fax:606-354-3830
Practice Address - Street 1:4160 S HWY 27
Practice Address - Street 2:
Practice Address - City:PINE KNOT
Practice Address - State:KY
Practice Address - Zip Code:42635
Practice Address - Country:US
Practice Address - Phone:606-354-2222
Practice Address - Fax:606-354-3830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP010403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54013933Medicaid
KY90007790Medicaid
2029239OtherPK
KY54013933Medicaid