Healthcare Provider Details

I. General information

NPI: 1992790984
Provider Name (Legal Business Name): COLLEGE SQUARE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 03/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 GLADES RD
BEREA KY
40403
US

IV. Provider business mailing address

PO BOX 1018
BEREA KY
40403
US

V. Phone/Fax

Practice location:
  • Phone: 859-986-0500
  • Fax: 859-986-0505
Mailing address:
  • Phone: 859-986-0500
  • Fax: 859-986-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP06904
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberP06904
License Number StateKY

VIII. Authorized Official

Name: MRS. ERIN E KNIGHT
Title or Position: OWNER
Credential:
Phone: 859-986-0500