Healthcare Provider Details

I. General information

NPI: 1093012841
Provider Name (Legal Business Name): OPTIMUM CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2367 STATE ROUTE 93 N
KUTTAWA KY
42055-5880
US

IV. Provider business mailing address

PO BOX 22
KUTTAWA KY
42055-0022
US

V. Phone/Fax

Practice location:
  • Phone: 270-625-9611
  • Fax: 270-388-0279
Mailing address:
  • Phone: 270-625-9611
  • Fax: 270-388-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012996
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number012996
License Number StateKY

VIII. Authorized Official

Name: SCOTT VANCE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: RPH, PHARM-D
Phone: 270-625-9611