Healthcare Provider Details

I. General information

NPI: 1235688920
Provider Name (Legal Business Name): LEWIS COUNTY PRIMARY CARE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 DEPOT DR
SOUTH SHORE KY
41175-9306
US

IV. Provider business mailing address

142 DEPOT DR
SOUTH SHORE KY
41175-9306
US

V. Phone/Fax

Practice location:
  • Phone: 606-932-2138
  • Fax: 606-932-2120
Mailing address:
  • Phone: 606-932-2138
  • Fax: 606-932-2120

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 NumberP07791
License Number StateKY

VIII. Authorized Official

Name: CHAD EVANS
Title or Position: DIRECTOR OF PHARMACY
Credential: PHARMD
Phone: 606-956-0188