Provider Demographics
NPI:1548487507
Name:HOMETOWN APOTHECARY
Entity type:Organization
Organization Name:HOMETOWN APOTHECARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-639-5242
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:KY
Mailing Address - Zip Code:42409-0289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 US HWY 41A S
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:KY
Practice Address - Zip Code:42409
Practice Address - Country:US
Practice Address - Phone:270-639-5242
Practice Address - Fax:270-639-6369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYPO63513336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1824994OtherOTHER ID NUMBER
KY54001086Medicaid