1538377114 NPI number — BRANDENBURG CUSTOM MEDS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538377114 NPI number — BRANDENBURG CUSTOM MEDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRANDENBURG CUSTOM MEDS 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:
1538377114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 BYPASS RD STE C
Provider Second Line Business Mailing Address:
P.O. BOX 455
Provider Business Mailing Address City Name:
BRANDENBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40108-1745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-422-2477
Provider Business Mailing Address Fax Number:
270-422-3299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 BYPASS RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDENBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40108-1745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-422-2477
Provider Business Practice Location Address Fax Number:
270-422-3299
Provider Enumeration Date:
05/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GODBY
Authorized Official First Name:
DALE
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-422-2477

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  P06557 , 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)