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General NPI Number Information
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NPI Number | 1285900860
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Entity Type | Organization
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Legal Business Name | BLUEGRASS DRUG STORE PLLC
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Dates
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Enumeration Date | 03/28/2012
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Last Update Date | 03/28/2012
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Provider Practice Location Address
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Address Line | 104 PONDER CT STE E&F
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City | DANVILLE
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State | KY
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Zip | 40422-9000
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Country | US
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Telephone | 859-236-3535
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Fax | 859-236-3035
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Provider Business Mailing Address
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Address Line | 104 PONDER CT STE E&F
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City | DANVILLE
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State | KY
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Zip | 40422-9000
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Country | US
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Telephone | 859-236-3535
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Fax | 859-236-3035
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Authorized Official
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Title or Position | CO-OWNER/PIC
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Name | MARK TAYLOR
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Credential |
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Telephone | 859-236-3535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | P07500
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License Number State | KY
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