Provider Demographics
NPI:1346427242
Name:BENTON DISCOUNT PHARMACY (EPSDT)
Entity type:Organization
Organization Name:BENTON DISCOUNT PHARMACY (EPSDT)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PHARMACY MGR
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-527-1409
Mailing Address - Street 1:2606 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1819
Mailing Address - Country:US
Mailing Address - Phone:270-527-1409
Mailing Address - Fax:270-527-2801
Practice Address - Street 1:2606 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1819
Practice Address - Country:US
Practice Address - Phone:270-527-1409
Practice Address - Fax:270-527-2801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENTON DISCOUNT PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-23
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP010493336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54013990Medicaid