Healthcare Provider Details

I. General information

NPI: 1942293246
Provider Name (Legal Business Name): COLLEGE DRUGSTORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 HEATHER WAY
SOMERSET KY
42503-9523
US

IV. Provider business mailing address

3810 HEATHER WAY
SOMERSET KY
42503-9523
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-4983
  • Fax:
Mailing address:
  • Phone: 606-679-4983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1113
License Number StateKY

VIII. Authorized Official

Name: MR. CHARLES E BLANCHI
Title or Position: OWNER
Credential: RPH
Phone: 606-679-4983