Provider Demographics
NPI:1427141159
Name:PAT'S PHARMACY, INC.
Entity type:Organization
Organization Name:PAT'S PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-692-4950
Mailing Address - Street 1:498 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1362
Mailing Address - Country:US
Mailing Address - Phone:270-692-4950
Mailing Address - Fax:270-692-2320
Practice Address - Street 1:498 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1362
Practice Address - Country:US
Practice Address - Phone:270-692-4950
Practice Address - Fax:270-692-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007247183500000X
KY90006735332B00000X
KY54019211332BP3500X
KY45542818332BP3500X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral NutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90006735Medicaid
KY000000070377OtherANTHEM BCBS
KY45542818OtherMEDICAID; EPSDT PROVIDER NO.
KY54019211Medicaid
KY0230070001Medicare ID - Type Unspecified