Provider Demographics
NPI:1316960453
Name:APOTHECARE PHARMACY OF ELIZABETHTOWN PSC
Entity type:Organization
Organization Name:APOTHECARE PHARMACY OF ELIZABETHTOWN PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:270-739-0303
Mailing Address - Street 1:1239 WOODLAND DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2770
Mailing Address - Country:US
Mailing Address - Phone:270-739-0303
Mailing Address - Fax:270-234-0101
Practice Address - Street 1:1239 WOODLAND DR STE 102
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2770
Practice Address - Country:US
Practice Address - Phone:270-739-0303
Practice Address - Fax:270-234-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
KYP06320332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54033097Medicaid
KY1214020001Medicare ID - Type Unspecified
KY54033097Medicaid