Healthcare Provider Details

I. General information

NPI: 1164485702
Provider Name (Legal Business Name): GRIDER DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 DOWELL RD
RUSSELL SPRINGS KY
42642-4278
US

IV. Provider business mailing address

PO BOX 1328
RUSSELL SPRINGS KY
42642-1328
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-2686
  • Fax: 270-866-6566
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP01425
License Number StateKY

VIII. Authorized Official

Name: ERIC GRIDER
Title or Position: PHARMACIST AND MANAGER
Credential:
Phone: 270-866-2686