Provider Demographics
NPI:1700873544
Name:PROFESSIONAL PHARMACY, LLC
Entity type:Organization
Organization Name:PROFESSIONAL PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLUSHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:606-679-1169
Mailing Address - Street 1:342 BOGLE ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2851
Mailing Address - Country:US
Mailing Address - Phone:606-679-1169
Mailing Address - Fax:606-679-1049
Practice Address - Street 1:342 BOGLE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2851
Practice Address - Country:US
Practice Address - Phone:606-679-7979
Practice Address - Fax:606-678-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KY6797333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000245485OtherANTHEM PROVIDER NUMBER
KY54004221Medicaid
KY90005240Medicaid
KY000000245485OtherANTHEM PROVIDER NUMBER