Provider Demographics
NPI:1326409475
Name:DIXIE PHARMACY-2 LLC
Entity type:Organization
Organization Name:DIXIE PHARMACY-2 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NAVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:YOONUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-872-0588
Mailing Address - Street 1:914 N DIXIE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2520
Mailing Address - Country:US
Mailing Address - Phone:270-900-1583
Mailing Address - Fax:270-900-1594
Practice Address - Street 1:1311 RING RD STE 107
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8968
Practice Address - Country:US
Practice Address - Phone:270-872-0588
Practice Address - Fax:270-872-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP077603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158876OtherPK
TX7100407790Medicaid