Provider Demographics
NPI:1730329277
Name:INGRAM PHARMACY PLLC DBA HOMETOWN PHARMACY
Entity type:Organization
Organization Name:INGRAM PHARMACY PLLC DBA HOMETOWN PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-588-2932
Mailing Address - Street 1:1134 US HIGHWAY 27 S
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-4177
Mailing Address - Country:US
Mailing Address - Phone:859-234-5600
Mailing Address - Fax:859-234-5606
Practice Address - Street 1:1502 OXFORD DR STE 150
Practice Address - Street 2:SUITE 150
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8095
Practice Address - Country:US
Practice Address - Phone:502-863-3784
Practice Address - Fax:502-863-3789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
KYP07328333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831076OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY7100067730Medicaid