Healthcare Provider Details

I. General information

NPI: 1376767129
Provider Name (Legal Business Name): CHARLES PATRICK CHILDERS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 FERGUSON BLVD
DRY RIDGE KY
41035-8635
US

IV. Provider business mailing address

191 THOROUGHBRED LN
WALTON KY
41094-8143
US

V. Phone/Fax

Practice location:
  • Phone: 859-824-5091
  • Fax:
Mailing address:
  • Phone: 859-363-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9874
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: