1134165152 NPI number — BIG SANDY HEALTH CARE INC

Table of content: (NPI 1134165152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134165152 NPI number — BIG SANDY HEALTH CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIG SANDY HEALTH CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHELBY VALLEY CLINIC PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134165152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1709 KY ROUTE 321
Provider Second Line Business Mailing Address:
SUITE 3 BIG SANDY HEALTH CARE INC
Provider Business Mailing Address City Name:
PRESTONSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41653-9101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-886-8546
Provider Business Mailing Address Fax Number:
606-886-8548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
178 DOUGLAS PKWY
Provider Second Line Business Practice Location Address:
SHELBY VALLEY CLINIC PHARMACY
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501-6970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-639-9045
Provider Business Practice Location Address Fax Number:
606-639-9997
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHOFNER
Authorized Official First Name:
BOYCE
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
606-886-8546

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  P06965 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54008172 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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