Provider Demographics
NPI:1992809958
Name:BON HARBOR RX, LLC
Entity type:Organization
Organization Name:BON HARBOR RX, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:NATION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-864-5398
Mailing Address - Street 1:3030 BURLEW BLVD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-6486
Mailing Address - Country:US
Mailing Address - Phone:270-684-5398
Mailing Address - Fax:270-685-5742
Practice Address - Street 1:415 CARTER RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301
Practice Address - Country:US
Practice Address - Phone:270-685-0557
Practice Address - Fax:270-688-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0003X
KYPO14333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90330309Medicaid
KY54017090Medicaid
2030122OtherPK
KY54017090Medicaid
KY90330309Medicaid
0520090001Medicare NSC