=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811049455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK COUNTY PHARMACY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 12/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520B BOONESBORO RD
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40391-8816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-744-3350
-----------------------------------------------------
Fax | 859-744-3325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520B BOONESBORO RD
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40391-8816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-744-3350
-----------------------------------------------------
Fax | 859-744-3325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NEVIN SCOTT GOEBEL
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 859-744-3350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | P06947
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------