Healthcare Provider Details

I. General information

NPI: 1912217589
Provider Name (Legal Business Name): LAKE CUMBERLAND PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431C LAKEWAY DR
RUSSELL SPRINGS KY
42642-4510
US

IV. Provider business mailing address

PO BOX 72
RUSSELL SPRINGS KY
42642-0072
US

V. Phone/Fax

Practice location:
  • Phone: 270-858-6400
  • Fax: 270-866-7542
Mailing address:
  • Phone: 270-585-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07417
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN GIDER
Title or Position: PHARMACIST-IN-CHARGE
Credential: PHARMD
Phone: 270-585-2221