Provider Demographics
NPI:1699869651
Name:PROFESSIONAL CENTER PHARMACY ANNEX
Entity type:Organization
Organization Name:PROFESSIONAL CENTER PHARMACY ANNEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:859-623-8065
Mailing Address - Street 1:793 EASTERN BY-PASS
Mailing Address - Street 2:SUITE G-01
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
Mailing Address - Country:US
Mailing Address - Phone:859-623-8065
Mailing Address - Fax:859-623-8065
Practice Address - Street 1:793 EASTERN BY-PASS
Practice Address - Street 2:SUITE G-01
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-623-8065
Practice Address - Fax:859-623-8065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO62493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1824386OtherNABP
KY54031968Medicaid
KYBP5015347OtherDEA