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General NPI Number Information
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NPI Number | 1710370580
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Entity Type | Organization
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Legal Business Name | ELY SPECIAL PHARMACY INC.
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Dates
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Enumeration Date | 03/18/2015
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Last Update Date | 03/18/2015
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Provider Practice Location Address
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Address Line | 4863C SCOTTSVILLE RD
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City | BOWLING GREEN
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State | KY
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Zip | 42104-7909
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Country | US
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Telephone | 270-467-5225
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Fax |
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Provider Business Mailing Address
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Address Line | 4863C SCOTTSVILLE RD
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City | BOWLING GREEN
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State | KY
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Zip | 42104-7909
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Country | US
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Telephone | 270-467-5225
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRAVIS HUDNALL
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Credential |
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Telephone | 270-467-5225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | P07674
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License Number State | KY
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