Provider Demographics
NPI:1992790984
Name:COLLEGE SQUARE PHARMACY
Entity type:Organization
Organization Name:COLLEGE SQUARE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-986-0500
Mailing Address - Street 1:PO BOX 1018
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403
Mailing Address - Country:US
Mailing Address - Phone:859-986-0500
Mailing Address - Fax:859-986-0505
Practice Address - Street 1:191 GLADES RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403
Practice Address - Country:US
Practice Address - Phone:859-986-0500
Practice Address - Fax:859-986-0505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLEGE SQUARE PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-15
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP06904332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54006085Medicaid
KY90008384Medicaid
KYP300037221OtherPTAN
KYP300037221OtherPTAN