1992104442 NPI number — SILVERS HOMETOWN PHARMACY, LLC

Table of content: (NPI 1992104442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992104442 NPI number — SILVERS HOMETOWN PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SILVERS HOMETOWN PHARMACY, 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:
Provider Other Organization Name Type Code:
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:
1992104442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1251 W COLUMBIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42633-3177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-343-0101
Provider Business Mailing Address Fax Number:
606-343-0041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 W COLUMBIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42633-3177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-343-0101
Provider Business Practice Location Address Fax Number:
606-343-0041
Provider Enumeration Date:
08/21/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHILDERS
Authorized Official First Name:
BRYCE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
606-343-0101

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  P07645 , 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: 1834565 . This is a "NCPDP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P07645 . This is a "PHARMACY PERMIT NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100660260 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".