MEDICARE: AUDUBON 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	P07058	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2034337	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306943147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUDUBON PHARMACY INC

Provider Business Mailing Address
First Line	:	3503 POPLAR LEVEL RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40213-1009
Country	:	US
Telephone Number	:	502-371-1002
Fax Number	:	502-371-1005

Provider Business Practice Location Address
First Line	:	3503 POPLAR LEVEL RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40213-1009
Country	:	US
Telephone Number	:	502-371-1002
Fax Number	:	502-371-1005

Authorized Official
Title or Position	:	OWNER
Name	:	TRACI ULLOM
Credential	:	RPH
Telephone Number	:	502-371-1002

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	12/29/2015

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Directions to “AUDUBON PHARMACY INC ” Practice Location

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