Healthcare Provider Details

I. General information

NPI: 1154661650
Provider Name (Legal Business Name): CORUM FAMILY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 S HIGHWAY 421
MANCHESTER KY
40962-7514
US

IV. Provider business mailing address

1668 S HIGHWAY 421
MANCHESTER KY
40962-7514
US

V. Phone/Fax

Practice location:
  • Phone: 606-599-0505
  • Fax: 606-599-0508
Mailing address:
  • Phone: 606-599-0505
  • Fax: 606-599-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPO7555
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RANDY WINDHAM
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 606-599-0505