MEDICARE: KY FOUR 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	3336C0003X	Community/Retail Pharmacy	054011204	IL

General Provider Information

NPI Number	:	1497817381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KY FOUR INC

Provider Business Mailing Address
First Line	:	450 W HANOVER ST
Second Line	:
City	:	NEW BADEN
State	:	IL
Zip	:	62265-1658
Country	:	US
Telephone Number	:	618-588-3517
Fax Number	:	618-588-4818

Provider Business Practice Location Address
First Line	:	450 W HANOVER ST
Second Line	:
City	:	NEW BADEN
State	:	IL
Zip	:	62265-1658
Country	:	US
Telephone Number	:	618-588-3517
Fax Number	:	618-588-4818

Authorized Official
Title or Position	:	PHARMACIST
Name	:	ROBERT NAVE
Credential	:
Telephone Number	:	618-588-3517

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	12/04/2008

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Directions to “KY FOUR INC ” Practice Location

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