=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295464162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEOFFREY GROENKE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2022
-----------------------------------------------------
Last Update Date | 06/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 NICHOLASVILLE RD STE 1210
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-639-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 N ASHLAND AVE
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40502-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-575-4787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 020540
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------