Provider Demographics
NPI:1386709400
Name:BRODHEAD PHARMACY INC
Entity type:Organization
Organization Name:BRODHEAD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-758-4373
Mailing Address - Street 1:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40409-0527
Mailing Address - Country:US
Mailing Address - Phone:606-758-4373
Mailing Address - Fax:606-758-4764
Practice Address - Street 1:54 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:KY
Practice Address - Zip Code:40409-8890
Practice Address - Country:US
Practice Address - Phone:606-758-4373
Practice Address - Fax:606-758-4764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP067273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2033827OtherPK
KY54002985Medicaid
2033827OtherPK