Provider Demographics
NPI:1134270119
Name:WHITESVILLE D S INC
Entity type:Organization
Organization Name:WHITESVILLE D S INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-836-4313
Mailing Address - Street 1:PO BOX 701
Mailing Address - Street 2:
Mailing Address - City:FLATWOODS
Mailing Address - State:KY
Mailing Address - Zip Code:41139-0701
Mailing Address - Country:US
Mailing Address - Phone:606-836-4313
Mailing Address - Fax:
Practice Address - Street 1:2205 ARGILLITE RD
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1692
Practice Address - Country:US
Practice Address - Phone:606-836-4313
Practice Address - Fax:606-617-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336L0003X, 3336S0011X, 332B00000X
KYP070573336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2034333OtherPK
KY54010483Medicaid
KY90012048Medicaid
1829160OtherOTHER ID NUMBER-COMMERCIAL NUMBER