Healthcare Provider Details

I. General information

NPI: 1083452387
Provider Name (Legal Business Name): GLASS ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 08/16/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E MAIN ST
MIDWAY KY
40347-5024
US

IV. Provider business mailing address

PO BOX 4344
MIDWAY KY
40347-4344
US

V. Phone/Fax

Practice location:
  • Phone: 859-846-4146
  • Fax: 859-846-4148
Mailing address:
  • Phone: 859-846-4146
  • Fax: 859-846-4148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH WAYNE GLASS
Title or Position: OWNER/PHARMACIST-IN-CHARGE
Credential: PHARMD
Phone: 859-846-4146