MEDICARE: PAT'S PHARMACY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
2	3336C0003X	Community/Retail Pharmacy	P06177	KY
3	333600000X	Pharmacy

General Provider Information

NPI Number	:	1295110526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAT'S PHARMACY, INC.

Provider Business Mailing Address
First Line	:	498 W MAIN ST
Second Line	:
City	:	LEBANON
State	:	KY
Zip	:	40033-1362
Country	:	US
Telephone Number	:	270-692-4950
Fax Number	:

Provider Business Practice Location Address
First Line	:	498 W MAIN ST
Second Line	:
City	:	LEBANON
State	:	KY
Zip	:	40033-1362
Country	:	US
Telephone Number	:	270-692-4950
Fax Number	:	270-692-2320

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOSEPH KELLY JOHNSON
Credential	:
Telephone Number	:	270-692-4950

Provider Enumeration Date	:	07/28/2015
Last Update Date	:	03/10/2022

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