1134393325 NPI number — RXSHOP, LLC

Table of content: (NPI 1134393325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134393325 NPI number — RXSHOP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RXSHOP, LLC
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:
SMITHS GROVE RX SHOP
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:
1134393325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 540
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42210-0540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-597-2181
Provider Business Mailing Address Fax Number:
866-233-8342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 N MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITHS GROVE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-563-2180
Provider Business Practice Location Address Fax Number:
855-457-9282
Provider Enumeration Date:
04/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY OPERATIONS MANAGER
Authorized Official Telephone Number:
270-597-2181

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  P07249 , 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: 2035132 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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