Healthcare Provider Details

I. General information

NPI: 1013979640
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: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431B LAKEWAY DR
RUSSELL SPRINGS KY
42642-4510
US

IV. Provider business mailing address

2431B LAKEWAY DR PO BOX 1328
RUSSELL SPRINGS KY
42642-4510
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-7541
  • Fax:
Mailing address:
  • Phone: 270-866-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP06731
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberP06731
License Number StateKY

VIII. Authorized Official

Name: MR. GREG GRIDER
Title or Position: MANAGER
Credential:
Phone: 270-866-7541