1295748051 NPI number — LAWRENCE RETAIL CO., INC.

Table of content: (NPI 1295748051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295748051 NPI number — LAWRENCE RETAIL CO., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE RETAIL CO., 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:
Provider Other Organization Name Type Code:
6
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:
1295748051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 N LOCK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISA
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41230-1115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-638-4155
Provider Business Mailing Address Fax Number:
606-638-1109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 N LOCK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41230-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-638-4155
Provider Business Practice Location Address Fax Number:
606-638-1109
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
LABAN
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
606-638-4155

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  P00260 , 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: 54012240 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90020645 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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